Care considerations for infants born to mothers with suspected or confirmed SARS-CoV-2 infection

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Background

Since December 2019, when SARS-CoV-2 first emerged, there have been significant changes to our understanding of the virus, its mode of transmission, and its clinical manifestations. While COVID-19 vaccines have greatly reduced disease severity and hospitalization rates, their efficacy for reducing infection rates and transmission is limited. Study data continue to show that SARS-CoV-2 is not commonly transmitted in utero or perinatally. When newborns become infected with SARS-CoV-2 at birth, most are asymptomatic or experience mild or moderate disease ^[1]. 

This updated statement addresses three areas of care for infants exposed to SARS-CoV-2 in the perinatal period:

• Risk for vertical transmission of SARS-CoV-2 and delivery room strategies to protect newborns and mothers/birthing persons with suspected or confirmed infection, 
• Neonatal intensive care unit (NICU) or regular nursery care for infants born to mothers with suspected or confirmed SARS-CoV-2 infection, and
• Breastfeeding and SARS-CoV-2.

Risk for vertical transmission

Recent systematic reviews suggest that while vertical transmission of SARS-CoV-2 remains rare, it likely does occur ^[1][2]. Based on the first 14,271 babies under study whose mothers had SARS-CoV-2, 1.8% had a positive reverse transcription-polymerase chain reaction (RT-PCR) test in the newborn period. Confirmed vertical transmission occurred in only 7 out of 592 babies whose sampling included an estimated time of exposure. The best risk estimate for vertical transmission at the present time is 0.01% of infants exposed to the virus in utero. The most convincing evidence for vertical transmission was reported in France, with amniotic fluid, surface swabs of the placenta, and maternal blood all testing positive for SARS-CoV-2 by PCR in one case. SARS-CoV-2 was also detected in a nasal swab specimen from the same infant obtained at 1 h post-birth. Viral load peaked at day 3 post-birth ^[3]. A second report from Canada of possible vertical transmission involved a woman with a chronic immunodeficiency. In this case, SARS-CoV-2 was detected by PCR in maternal and fetal placental surface swabs. Three nasal swabs from the newborn, including a sample on the day of delivery, also tested positive ^[4]. Case reports relying solely on serology have been less convincing ^[5][6]. 

Risk factors for vertical transmission include severe maternal COVID-19 infection, maternal death, and maternal admission to an intensive care unit ^[1].

One significant finding based on early variants worldwide was a decreased likelihood of acquiring COVID-19 in childhood, particularly during the neonatal period. While some protection is afforded through maternal vaccination and breastfeeding, infants demonstrated an inherently low likelihood of infection generally. This level of protection is likely attributable to low concentrations of ACE-2 and TMPRSS2 receptors in the nasal mucosae of newborns, which limit viral access to the infant host. Interaction with these receptors has been identified as the main route by which early SARS-CoV-2 variants gained access to new hosts ^[7]. As expression of these receptors in nasal mucosae increases with age, the frequency of illness is also more likely to rise ^[8]. It is worth noting that omicron subvariants may be relatively more transmissible due to their endocytic entry into respiratory tract cells. Unlike earlier variants, this mechanism is not dependent on TMPRSS2 receptors and viral replication is not confined to the lung ^[9].

Precautions at delivery for mothers/birth persons with suspected or confirmed SARS-CoV-2 infection

All perinatal care practitioners must be aware of and adhere to local infection prevention and control (IPAC) recommendations. 

Precautions when attending a delivery are based on three considerations: 

1. The differential diagnosis for neonatal respiratory distress is broad, including both infectious and non-infectious conditions. While SARS-CoV-2 is an important consideration, the full differential diagnosis should be considered in all cases.  
2. Neonatal resuscitation team attendance at delivery when mothers have confirmed SARS-CoV-2 infection is not routine, unless there are other signs of fetal distress or a need to resuscitate is anticipated. To minimize potential staff exposure, only essential skilled personnel should attend.
3. Higher risk of SARS-CoV-2 transmission is present during aerosol generating medical procedures (AGMPs), particularly when administering positive pressure ventilation (PPV) or continuous positive airway pressure (CPAP), and during intubation. 

Cord management

Because it is unlikely that SARS-CoV-2 will be transmitted during deferred (delayed) cord clamping, this practice should continue based on its known benefits.

Post-partum care for mothers with SARS-CoV-2 infection and their newborns: The symptomatic infant

Clinicians should always consider the full differential diagnosis of respiratory distress in any newborn. Although SARS-CoV-2 is a possibility, this infection is rarely the cause of respiratory distress in newborn infants. One systematic review of 26 observational studies that included 44 newborns with confirmed SARS-CoV-2 infection found 25% to be asymptomatic, with the remainder having mild respiratory or gastrointestinal symptoms only ^[10].

Precautions for the symptomatic patient in the NICU

When caring for infants born to mothers with SARS-CoV-2 infection, the use of IPAC precautions is recommended until SARS-CoV-2 infection has been excluded in the infant. Furthermore, IPAC precautions combined with specific local guidance (where applicable) should be implemented when a neonate develops new-onset respiratory symptoms. Wearing an N-95 mask is recommended for AGMP involving neonates with unexplained respiratory symptoms.

Decisions regarding bed allocation and the cohorting of infants born to mothers/birth persons with suspected or confirmed SARS-CoV-2 infection should be made at the time of admission. Infants with suspected or confirmed SARS-CoV-2 infection should be placed in a single patient room, if possible, or cohorted separately in the NICU when a single room is not available. When an infant with SARS-CoV-2 infection has mild respiratory distress not requiring PPV support, admission to a single patient room is optimal. A symptomatic infant born to a mother with suspected or confirmed SARS-CoV-2 infection who requires PPV or CPAP support should be admitted to a negative pressure isolation room or to a single patient room with a door that can be closed. Placement of a HEPA filter on the expiratory limb of the patient’s respiratory device is recommended ^[11].

Care of asymptomatic infants born to COVID-positive mothers

Ideally, asymptomatic infants with no requirement for NICU care should remain in-room with their mothers. Newborns of COVID-positive mothers who are admitted to NICU for conditions such as hyperbilirubinemia or hypoglycemia, but with no respiratory symptoms, should be tested for SARS-CoV-2. Consultation with local IPAC experts is recommended to determine additional precautions for care on a case-by-case basis. 

In-hospital neonatal transport

Hospitals must develop safe procedures and pathways for transporting symptomatic infants born to mothers with SARS-CoV-2 infection. An infant on respiratory support should be transported to the NICU in compliance with institutional practice and in consultation with IPAC. When infants are asymptomatic at birth and NICU care is not required, routine transport in an open bassinet with their mothers to a post-partum hospital room is appropriate.

Outborn transport

Air or ground transport personnel work in close quarters, and an infant’s condition often evolves during transport. There are no data at present to guide protocols for the outborn transport of infants whose mothers are SARS-CoV-2-positive. Physicians and transport coordinators must consider the following factors: risk for infection in the infant, transmission risk, the infant’s age and clinical condition, duration and conditions of transport, and necessary ventilatory support requirements. 

The transportation of infants with suspected or confirmed SARS-CoV-2 infection should be timely. Avoid delay, and any infant with respiratory distress requiring PPV should be transported to the nearest NICU. The following precautions also apply:

• Newborns of mothers testing positive for SARS-CoV-2 should be transported as suspected COVID cases, even if the likelihood of their being infected appears low.
• Follow local IPAC and workplace health guidance when transporting patients with SARS-CoV2 infection. Be especially careful to use droplet and contact precautions and to wear an N-95 mask (or equivalent) in enclosed spaces and when social distancing among individuals is difficult to maintain.

Newborn testing

The need to swab newborns for SARS-CoV-2 infection at 2 h of age to determine whether vertical transmission has occurred may no longer be as urgent as earlier in the pandemic. Recommendations for the testing of infants with suspected SARS-CoV-2 infection, whether vertically or horizontally acquired, should be based instead on clinical symptoms and differential diagnosis. 

Parental presence

COVID-19-related social distancing practices have led to more restrictive hospital policies regarding parental presence in some centres. When their presence at the hospital is not possible, telehealth can help include parents in rounds and family meetings.

The Family Integrated Care Steering Group has offered an approach that balances the benefits of involving parents in infant care with mitigating risk in the era of COVID-19: 

“It is vital that parents are involved as they are an essential and irreplaceable component in the care of their infant. Parents should be able to spend unrestricted and unlimited time with their infant on the neonatal unit; the benefits are well documented and have life-long effects for both infant and parents e.g. breast-feeding rates are higher, neurodevelopmental outcomes in children improve, and reduced length of hospital stay. Having an infant in neonatal care can cause significant issues including mental health problems for parents. This is significantly improved with unrestricted access for parents to their infant in the neonatal unit along with participation in care, education and psycho-social support” ^[12].

Mother-baby units and “neonatal teams should make every effort to provide additional measures to support parental presence during COVID-19, including the provision of face masks, accommodation, parking and transport” ^[12].

Breastfeeding and COVID-19

Maternal hospital-based care for women with confirmed or suspected SARS-CoV-2 infection and their newborns

Mothers being investigated (or found to be positive) for SARS-CoV-2 infection should not be separated from their infants. Rooming-in should occur after a discussion of risks and benefits, thereby allowing for shared decision-making with families and their health care providers. Some evidence suggests that infants can be infected with SARS-CoV-2 postnatally ^[13]. Preventing postnatal infection should focus on enhanced hygiene and mask-wearing to limit risk for transmission.   

Mothers should practice skin-to-skin care and breastfeed while in hospital, with some modifications to usual processes. They should practice meticulous hand hygiene, don a well-fitting mask within 2 metres of their infant, and clean hands before skin-to-skin contact, breastfeeding, and other routine infant care. Mother and infant should be discharged as soon as appropriate to convalesce at home in accordance with hospital guidance and local public health recommendations.

Mothers with SARS-CoV-2 infection who breastfeed

In one living systematic review, no cases of newborn infection could be attributed conclusively to breast milk transmission ^[14].  Maternal antibodies to SARS-CoV-2 are believed to pass to the newborn and convey protective benefit ^[15][16]. Regarding the presence of SARS-CoV-2 in human milk, the same review found that 9 of 84 samples of human milk tested positive for SARS-CoV-2 by PCR. Six infants were exposed to SARS-CoV-2-positive milk, and four tested positive for SARS-CoV-2. A series of patients from Israel found 0/55 infants contracted SARS-CoV-2 from breastfeeding, even after discharge ^[16].

A systematic review of neutralizing antibody levels in human milk from unvaccinated women found that 82.6% of milk samples contained anti-SARS-CoV-2-specific IgA, IgG, and/or IgM ^[17], and that 41.7% of these antibodies had neutralizing activity in vitro against SARS-CoV-2. Another study, of 84 vaccinated women who provided 504 samples of human milk, found that 61.8% had anti–SARS-CoV-2-specific IgA antibodies in their milk 2 weeks after receiving their first vaccine dose, a cohort that increased to 86.1% at week 4 (1 week after the second vaccine). Anti-SARS-CoV-2-specific IgG antibodies were low for the first 3 weeks but had increased by week 4, when 92% of samples tested positive ^[18]. At weeks 5 and 6, 97% of women sampled had detectable SARS-CoV-2 IgG. Another study found that antibody levels in human milk following vaccination persisted above pre-vaccination levels for up to 6 months post-vaccination ^[19]. Such results suggest that protecting unvaccinated infants via human milk will be an important public health strategy moving forward.

However, the continual emergence of new variants makes keeping up-to-date with vaccines even more essential. 

Regardless of vaccine status, the primary concern for a mother testing positive for SARS-CoV-2 infection is that the virus will pass to her infant via respiratory droplets transmitted while breastfeeding. Mothers who breastfeed should wear a mask and practice hand hygiene before placing their infant to breast. When a mother coughs or sneezes with chest exposed, she should cleanse the breast area with soap and water before feeding as a precaution. Mothers choosing to express milk should wash their hands and clean the pump and other equipment involved. At home, household surfaces that are touched frequently should be disinfected regularly.

When a mother is too ill to breastfeed due to SARS-CoV-2 infection (or for any other cause), they should be encouraged and supported to express milk. Pumped human milk can be supplied safely, provided that local IPAC guidelines are followed. When institutional IPAC policies prevent the presence of mothers/birth persons in the NICU because they have suspected or confirmed SARS-CoV-2 infection, they should be encouraged to pump at home and provide expressed human milk to the NICU. Those expressing at home should pump frequently, with a view to establishing consistent breastfeeding when they are able to be with their infant again. Hospitals should support breastfeeding by providing ready access to lactation experts and services and promoting virtual appointments when face-to-face consultation is not possible.

For more information on breastfeeding after receiving a COVID-19 vaccine, refer to the Society of Obstetricians and Gynaecologists of Canada’s Statement on COVID-19 Vaccination in Pregnancy ^[20].

Acknowledgements

This practice point was reviewed by the Infectious Diseases and Immunization Committee of the Canadian Paediatric Society.

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CANADIAN PAEDIATRIC SOCIETY FETUS AND NEWBORN COMMITTEE (2022)

Members: Gabriel Altit MD, Anne-Sophie Gervais MD (Resident Member), Heidi Budden MD (Board Representative), Souvik Mitra MD MSC FRCPC, Michael R. Narvey MD (Chair), Eugene Ng MD, Nicole Radziminski MD

Liaisons: Douglas Wilson MD (The Society of Obstetricians and Gynaecologists of Canada), Eric Eichenwald MD (Committee on Fetus and Newborn, American Academy of Pediatrics), William Ehman MD (College of Family Physicians of Canada), Danica Hamilton RN (Canadian Association of Neonatal Nurses), Emer Finan MBBCh (CPS Neonatal-Perinatal Medicine Section Executive), Chantal Nelson PhD (Public Health Agency of Canada)

Principal authors: Michael Narvey MD, Emer Finan MBBCh

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.