Separating Babies and Mothers for COVID-19

Some clinicians and patients alike are uneasy about recent guidance for obstetric care from the US Centers for Disease Control and Prevention (CDC).

Troy Brown, RN

Some clinicians and patients alike are uneasy about recent guidance for obstetric care from the US Centers for Disease Control and Prevention (CDC). Some experts say the recommendation to separate mothers with confirmed or suspected COVID-19 from their infants after delivery is not supported by evidence and could cause lasting harm.

"The evidence that has come out of early infections in China demonstrate that the risk of vertical transmission from mother to newborn is very low and the coronavirus has not been detected in human breast milk," said Sue Kehl, MSN, RN, CCRN, executive director of inpatient acute nursing at Santa Clara Valley Medical Center in California.

However, the CDC recommendations emphasize that separation should be considered. "To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (eg, separate rooms) the mother who has confirmed COVID-19 or is a PUI [person under investigation] from her baby until the mother's transmission-based precautions are discontinued," the recommendations state.

In addition, because the infant would have been exposed during birth, the recommendations continue, hospitals should consider housing the infant in a separate isolation room until he or she is no longer considered a PUI.

But these actions may not be necessary, and newborns need to breast-feed frequently to establish breast-feeding habits and to benefit from everything it has to offer, another expert told Medscape Medical News.

'No Good Evidence

"People talk about antibodies in breast milk, but it's so much more than that," Anne Eglash, MD, IBCLC, clinical professor at the University of Wisconsin School of Medicine and Public Health in Madison and cofounder of the Academy of Breastfeeding Medicine, told Medscape Medical News.

"There's hundreds, if not thousands, of bioactive factors that support that infant, and this is not the time to risk infants being artificially fed," she said. "We know for a fact that when babies are artificially fed the risks for hospitalization [and] for severe infections such as pneumonias and meningitis are much higher.

"There's just no good evidence that we should be separating these moms and babies," Eglash added.

Kehl agrees. "When you consider the effects on maternal–infant bonding and how important evidence-based practices, like performing skin-to-skin and early breastfeeding initiation [are], in most cases those benefits outweigh the risk of infection," she said.

"Infection exposure can be reduced with proper hand hygiene and maternal masking if needed," she added.

"[E]ssential information is emerging every day. We need to act wisely and urgently to protect mothers and newborns. And we also need to protect our nurses, midwives, and physicians from the risks of COVID-19 exposure as we support women with labor," James Byrne, MD, chair of the Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center, San Jose, California, told Medscape Medical News, adding that the recommendations "offer an excellent framework."

"I practice in Santa Clara county, which had one of the earliest identified cases of community-acquired COVID-19," Byrne said.

"When that case was identified, we quickly enacted the CDC guidelines for our labor and delivery and postpartum units. We also began actions such as social distancing at work and staff education on preventive measures," Byrne explained.

WHO Recommendations Allow 'More Close, Intimate Contact'

It is safe to feed a newborn expressed milk from a mother with COVID-19. Both the CDC guidelines as well as more recent guidelines from the World Health Organization [WHO] support maternal breast milk. The CDC guidelines were written in mid-February when cases in the United States were very isolated.

"The WHO guidelines may be more practical in preparation for the home environment given the current widespread community transmission in most areas of our country," Byrne said.

WHO's recommendations allow "more close, intimate contact" because it recognizes that it may be feasible to separate a newborn from its mother in an environment such as a hospital, but that once the infant goes home, he or she will likely be exposed, he explained.

CDC Guidance Leaves Ultimate Choice to Mother

To women considering a home birth as a result of the pandemic, the Society for Maternal-Fetal Medicine (SMFM) says that problems can develop quickly, and ambulance services may be unavailable if the mother or baby need them.

SMFM also warns against transferring care to another hospital or geographic area with fewer COVID-19 cases. Transferring to another hospital may mean switching to a provider who does not know the mother, and going to a region with fewer cases may spread the disease, the society writes.

"People should stay on their toes," Byrne warned. "Take infection prevention very seriously and stay abreast of the emerging best practices. That could be a challenge with all the onslaught of information overload."

"It's more important than ever for physicians to read the updated guidelines from national organizations, including the CDC, ACOG [American College of Obstetricians and Gynecologists], and the SMFM," Byrne explained.

The situation is changing rapidly; changes that a hospital institutes one day may change the next as infection-control experts update recommendations.

As the CDC explains, its approach is "intentionally cautious until additional data become available to refine recommendations for prevention of person-to-person transmission in inpatient obstetric care settings."

The CDC guidance does leave the ultimate choice with the mother, allowing her to opt to room with her infant, even if the mother has tested positive for the virus that causes COVID-19.

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Eglash and Kehl both emphasized the need for shared decision-making between the patient and clinical team. "Of course, proper education regarding practices to reduce transmission are important to protect the infant," Kehl said. "Ultimately, the choice to separate the [mother and infant] should lie with the mother as with any other medical decisions."

"In reality, hospitals do not have the space to separate the baby and the mom — it's just not going to happen," Eglash said.

Byrne, Eglash, and Kehl have disclosed no relevant financial relationships.

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References
SOURCE: Medscape, April 6, 2020.
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