Infectious Disease>COVID-19

Study Shows New Moms With Mild COVID-19 Can Care for Their Babies Safely

-Only one newborn diagnosed with SARS-CoV-2 during follow-up

by Zeena Nackerdien PhD, CME Writer, MedPage Today 2020-12-19  –  

Study Shows New Moms With Mild COVID-19 Can Care for Their Babies Safely | MedPage Today

Study Authors: Andrea Ronchi, Carlo Pietrasanta, et al.; David A. Kaufman, Karen M. Puopolo

Target Audience and Goal Statement: Pediatricians, infectious disease specialists, obstetrician-gynecologists

The goal of this study was to assess the risk of postnatal transmission of SARS-CoV-2 from infected mothers to their newborns following rooming-in and breastfeeding.

Question Addressed:

  • Were rooming-in and breastfeeding safe for newborns born to mothers infected with SARS-CoV-2?

Study Synopsis and Perspective:

Given that healthcare providers knew little about COVID-19 during the initial phase of the pandemic, developing guidance for pregnant women and their newborns was a challenge. Respiratory secretions and saliva are key vehicles for human-to-human transmission of SARS-CoV-2, and the possible transmission of the virus to babies of infected mothers has been a concern.

Action Points

  • Mother-to-infant transmission of SARS-CoV-2 during rooming-in practice is rare, provided that adequate droplet and contact precautions are taken, according to a multicenter cohort study from Italy.
  • Note that around three-quarters of babies were exclusively breastfed, suggesting that breast milk may have played a protective role.

However, the only data at the start of the COVID-19 pandemic came from China, where all newborns were immediately separated from infected mothers and isolated for 14 days.

Therefore, temporary mother-infant physical separation formed part of initial American Academy of Pediatrics (AAP) infection control practices to protect newborns from acquiring SARS-CoV-2 infection.

The AAP and other experts had drawn up guidelines based on scant data, recommending either separation or encouraging protected rooming-in under appropriate precautions.

However, the AAP later revised these guidelines, recommending mothers room-in with their babies as long as they are well enough to care for them.

According to a multicenter cohort study in Italy, mother-to-infant transmission of SARS-CoV-2 during rooming-in practice is rare, provided that adequate droplet and contact precautions are taken.

Of 62 infants, only one (1.6%) became infected with COVID-19 illness after staying in the same room with the mother after birth, reported Andrea Ronchi, MD, of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan, and colleagues in JAMA Pediatrics.

The baby who acquired an infection was born to the only mother who developed severe illness, suggesting that rooming-in was safe for new mothers with milder disease when following infection control protocols, they noted.

Ronchi and colleagues conducted this prospective cohort study at six COVID-19 maternity centers in Italy’s Lombardy region from mid-March to early May 2020. Infants were excluded if they received a positive SARS-CoV-2 PCR test the day after birth.

Mothers infected with COVID-19 were defined as those who received a positive test anytime between 14 days before delivery up until a few days after birth. Eligibility criteria for rooming-in for the mothers included no need for respiratory support or supplemental oxygen, temperature less than 38° C, vital signs within the reference ranges, and feeling well enough to care for their infants.

Of the 61 mothers, 75% had a vaginal delivery, and average age was 32. Seventy-two percent tested positive for COVID-19 before delivery, 23% were under investigation at delivery, and 5% were diagnosed 2-5 days postpartum because of emergent symptoms. Testing for all mothers at delivery became mandatory partway through the study period. Among the mothers who tested positive for COVID-19, 55% were asymptomatic at diagnosis and 70% were asymptomatic at the time of delivery.

A total of 62 infants born to the 61 mothers were included in the study. None of the babies tested positive for COVID-19 within 24 hours of birth. Some 95% of babies were breastfed at some point and 73% exclusively. Babies were eligible for rooming-in when they had a gestational age ≥34 weeks, a birth weight ≥2,000 g, appeared well, a physical examination within normal limits, vital signs within the reference ranges, and were skilled in feeding.

Clinicians educated all mothers about rooming-in guidelines, which included handwashing, donning a surgical mask during breastfeeding or when providing care to the infant, and otherwise physical distancing (2 m) from the infant. Visitors were not permitted during the hospital stay.

Babies underwent PCR testing via nasopharyngeal swab within 24 hours of birth, and again at 1 week when healthy babies were discharged. They were tested once more at a post-discharge check-up with a neonatologist, 20 days after birth.

For the one infant who tested positive for COVID-19 before hospital discharge, the mother became increasingly ill on day 5 after birth, with symptoms progressing from isolated, mild cough to bilateral pneumonia and pulmonary embolism requiring intensive care unit (ICU) admission and mechanical ventilation for 14 days.

On day 7, her baby tested positive and developed mild respiratory distress. The infant remained positive for SARS-CoV-2 at day 18, but was well enough for hospital discharge. Ultimately, the baby tested negative on day 30.

Six other newborns were admitted to the neonatal ICU for mild fetal distress, feeding difficulty, and hyperbilirubinemia.

Ronchi and colleagues noted that the study’s sample was relatively small, and there was no proper control group, which may have limited the findings. Additionally, viral load was unmeasured and the researchers did not assess breast milk as a possible mode of COVID-19 transmission.

Source References: JAMA Pediatrics 2020; DOI: 10.1001/jamapediatrics.2020.5086

Editorial: JAMA Pediatrics 2020; DOI: 10.1001/jamapediatrics.2020.5100

Study Highlights and Explanation of Findings:

Vertical SARS-CoV-2 transmission was rare when newborns were allowed to stay with COVID-infected mothers, according to a prospective cohort study from Italy.

All of the babies were followed for 3 weeks, and only one was diagnosed with COVID-19 during follow-up.

Around three-quarters of babies were exclusively breastfed, the researchers noted, suggesting that breast milk may have played a protective role. They hypothesized that protection may have been transferred through direct transmission of specific IgA, or indirectly through other immunity-boosting mechanisms.

« We believe that SARS-CoV-2-infected mothers in good clinical condition and willing to take care of their babies should be encouraged to practice rooming-in and breastfeeding after being carefully instructed about the appropriate droplet and contact precautions, » Ronchi and team wrote.

In an accompanying editorial, David Kaufman, MD, of the University of Virginia School of Medicine, and Karen Puopolo, MD, PhD, of the Children’s Hospital of Philadelphia, stated that these findings are reassuring for clinicians and patients who want to practice rooming-in and breastfeeding.

However, they added that it is important to analyze these findings using what we know about how the virus is shed, and when mothers are potentially infectious to their babies. The single case of transmission in this study occurred in an infant whose mother’s illness worsened in the postpartum period — a sign that the mother was likely infectious after delivery.

« The AAP revised guidance also supports the critical lesson of this study, » Kaufman and Puopolo wrote. « For mothers who are potentially infectious with SARS-CoV-2 at the time of delivery, preventive measures should be taken, as newborns are at risk of acquiring the virus from mothers who are truly infectious. »

Additionally, they noted that families can be assured that studies like this one are ending the « evidence-free zone » regarding neonatal COVID-19 guidelines.

« For newborns, this accumulation of evidence is ensuring that, with proper precautions, they can stay where they belong: with their mothers, » they wrote.

Reviewed by Dori F. Zaleznik, MD Associate Clinical Professor of Medicine (Retired), Harvard Medical School, Boston

Primary Source

JAMA Pediatrics

Source Reference: Ronchi A, et al « Evaluation of rooming-in practice for neonates born to mothers with severe acute respiratory syndrome coronavirus 2 infection in Italy » JAMA Pediatr 2020; DOI: 10.1001/jamapediatrics.2020.5086.

Secondary Source

JAMA Pediatrics

Source Reference: Kaufman DA, Puopolo KM « Infants born to mothers with COVID-19 — making room for rooming-in » JAMA Pediatr 2020; DOI: 10.1001/jamapediatrics.2020.5100.

Additional Source

MedPage Today

Source Reference: D’Ambrosio A « Rooming-In, Breastfeeding Appear Safe for New Moms With COVID-19 » 2020.