Archive, last updated July 2021
Guidance, recommendations, studies, and research of Interest for parents navigating the NICU, SARS-CoV-2, and COVID-19
I have compiled the latest guidance, recommendations, and studies I believe may be helpful to pregnant people and parents with newborns in the NICU. There isn’t a lot of data available on preterm infants and Coronavirus—a lack of reported cases and complications may suggest that preterm infants, newborns, and children in general are not the prime targets of SARS-CoV-2 and its known variants. Most newborns born to mothers who are COVID-19 positive do not become infected. Those who do become infected usually remain symptom free, and of those babies who do develop symptoms they remain well and recover.
The best information we have right now based on what is known about COVID-19 infection and outcomes in pregnant and newly postpartum parents, newborns, infants, and even neonates, supports that birthing parents and babies should remain together, that breast/chestfeeding and human milk feeding remains the ideal source of nutrition, and that close contact for kangaroo care and other opportunities to provide comfort and connection should be supported. Guidance from the World Health Organization (WHO) for term newborns supports this as true even when a parental case of COVID-19 is suspected or confirmed. The Centers For Disease Control (CDC) and the American Academy of Pediatrics suggest separating newborns from COVID-19 suspected or confirmed birthing parents but guidance relies on shared-decision making and parent preferences for implementation.
The American Academy of Pediatrics (AAP) offers the only NICU-specific guidance so far, and notes that parents who are COVID-19-suspected or confirmed should NOT visit their newborns in the NICU until cleared of the virus.
There are NO Universal NICU-specific recommendations or guidelines for healthy, asymptomatic parents with regard to parenting in the NICU during a pandemic. Both Hospitals and parents need universal guidance to set a standard of care that centers families, provides clarity that parents are not visitors in the NICU, and prioritizes Parents as essential in order to protect the mother-baby dyad—especially for NICU families that are already at higher risk for trauma and perinatal mood disorders (PMADS).
Resources are categorized under Guidance and Recommendations, and Studies and Research; they are listed most recent first and will be updated as more information is released.
EDIT: (What is known about SARS-CoV-2 and COVID-19, as well as the scientific and medical responses based on the most current evidence, is ever-changing as new variants and data emerge. This resource was last updated in July 2021 and will not be updated further.)
Guidance and Recommendations
ACOG and SMFM Recommend COVID-19 Vaccination for Pregnant Individuals
(July 2021, ACOG)
The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM), the two leading organizations representing specialists in obstetric care, recommend that all pregnant individuals be vaccinated against COVID-19. The organizations’ recommendations in support of vaccination during pregnancy reflect evidence demonstrating the safe use of the COVID-19 vaccines during pregnancy from tens of thousands of reporting individuals over the last several months, as well as the current low vaccination rates and concerning increase in cases.
COVID-19 Vaccines While Pregnant or Breastfeeding
(Updated May 14, 2021, Centers For Disease Control and Prevention)
This page discusses the latest data and considerations for Covid-19 vaccination safety and choice in pregnant and lactating people.
Scientific Brief: SARS-CoV-2 Transmission
(Updated May 7, 2021, Centers for Disease Control and Prevention)
SARS-CoV-2 is transmitted by exposure to infectious respiratory fluids. The principal mode by which people are infected with SARS-CoV-2 (the virus that causes COVID-19) is through exposure to respiratory fluids carrying infectious virus. Exposure occurs in three principal ways: (1) inhalation of very fine respiratory droplets and aerosol particles, (2) deposition of respiratory droplets and particles on exposed mucous membranes in the mouth, nose, or eye by direct splashes and sprays, and (3) touching mucous membranes with hands that have been soiled either directly by virus-containing respiratory fluids or indirectly by touching surfaces with virus on them.
People release respiratory fluids during exhalation (e.g., quiet breathing, speaking, singing, exercise, coughing, sneezing) in the form of droplets across a spectrum of sizes. These droplets carry virus and transmit infection.
Vaccinating Pregnant and Lactating Patients Against COVID-19
(December 2020, last updated April 28, 2021. Practice Advisory, American College of Obstetrics and Gynecology)
This Practice Advisory is intended to be an overview of currently available COVID-19 vaccines and guidance for their use in pregnant and lactating patients.
Essential Care in the NICU During the COVID-19 Pandemic
(January 2021, AWHONN, National Association of Neonatal Nurses, Perinatal Association)
In this consensus statement, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), the National Association of Neonatal Nurses (NANN), and the National Perinatal Association (NPA) recognize the unique challenges facing healthcare providers in reducing the risks of COVID-19 transmission while encouraging parent presence and engagement in care. AWHONN, NPA, and NANN believe that NICU parents are "essential caregivers," and when following the local health directive measures they should be provided unrestricted access to their hospitalized infants.
Evaluation and Management Considerations for Neonates At Risk for COVID-19
(December 8, 2020, Centers for Disease Control.)
Summary of current guidance about the diagnosis, evaluation, infection prevention and control practices, and disposition of neonates (≤28 days old) with suspected or confirmed SARS-CoV-2 infection or known SARS-CoV-2 exposure, including birth to a mother with suspected or confirmed COVID-19.
Vaccinating Pregnant and Lactating Patients Against COVID-19, Practice Advisory
(December 2020, American College of Obstetrics and Gynecology)
ACOG recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on ACIP-recommended priority groups. While safety data on the use of COVID-19 vaccines in pregnancy are not currently available, there are also no data to indicate that the vaccines should be contraindicated, and no safety signals generated from Developmental and Reproductive Toxicity (DART) studies for the Pfizer-BioNtech and Moderna COVID-19 vaccines. In the interest of allowing pregnant individuals who would otherwise be considered a priority population for vaccines approved for use under EUA to make their own decisions regarding their health, ACOG recommends that pregnant individuals should be free to make their own decision in conjunction with their clinical care team. (For more on decision making, read the companion document COVID-19 Vaccines and Pregnancy Conversation Guide here.)
FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19
(July 22, 2020. American Academy of Pediatrics.)
This Frequently Asked Questions document provides an update on previous guidance published by the AAP on May 21, and focuses on initial guidance for the management of infants born to mothers with confirmed and suspected COVID-19. Of note: rooming-in with newborns is considered ok, with precautions, and for NICU Visitation: how to determine if a former COVID-19 positive parent is no longer contagious.
If you are not immunocompromised and have been fever free for 24 hours (without use of fever-reducing medicine), and it has been 10 days since your symptoms began, you may return to parenting your baby in the NICU. While previous recommendations suggested a choice of two strategies (symptom-and time-based and test-based) to determine when a potential NICU visitor is still contagious, even parents who are fully recovered can still test positive by PCR testing for weeks and months, which has been a problem and can unnecessarily restrict visitation. The test-based approach is now reserved for rare circumstances.
Mothers with suspected or confirmed COVID-19 can room-in with their well newborns.
FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19
(May 21, 2020. American Academy of Pediatrics.)
This Frequently Asked Questions document provides an update on previous guidance published by the AAP on May 21, and focuses on initial guidance for the management of infants born to mothers with confirmed and suspected COVID-19. Of note, the document includes answers to the questions: What should I do if the infant requires intensive care? and When can I let the mother and her partner visit their newborn if the infant is in the NICU? It also covers the recommended methods used to determine when parents are no longer infectious.
FAQ Breastfeeding, Skin to Skin, and COVID-19
(April 28, 2020, World Health Organization)
This FAQ compliments the WHO interim guidance: Clinical management of severe acute respiratory Infection when COVID-19 disease is suspected and provides responses to questions that have come up about the recommendations.
Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings, Mother Baby Contact
(April 4, 2020. Centers for Disease Control)
The Center for Disease Control’s current recommendation for infants born to a birthing parent with confirmed or suspected COVID-19 is to consider the newborn a Patient Under Investigation (PUI) and to isolate the infant from the birthing parent until the birthing parent’s transmission-based precautions are discontinued. However, the CDC also states that a mother’s preference or wishes for rooming in must also be considered as a part of shared-decision making.
Guidance on Infants Born to Mother's with Suspected or Confirmed COVID-19
(April 2, 2020. American Academy of Pediatrics (AAP))
The American Academy of Pediatrics has issued guidance on infants born to mothers with suspected or confirmed COVID-19. There is no mention of how healthy, asymptomatic Parent visitation in the NICU should be addressed.
NICU specific guidance includes the following:
Intensive care: Infants requiring neonatal intensive care ideally should be admitted to a single-patient room with the potential for negative room pressure or other air filtration system. If unavailable, or if the center must cohort multiple COVID-exposed infants, there should be at least 6 feet between infants and/or they should be placed in air temperature-controlled isolettes. For the care of infants requiring continuous positive airway pressure or any form of mechanical ventilation, staff should wear a gown and gloves, with either an N95 respiratory mask and eye protection goggles, or with an air-purifying respirator that provides eye protection.
Visitation in neonatal intensive care units (NICUs): Mothers who have COVID-19 should not visit their infants in NICUs until all of the following conditions are met:
Resolution of fever without the use of antipyretics for at least 72 hours and improvement (but not full resolution) in respiratory symptoms, and
Negative results of a COVID-19 test from at least two consecutive specimens collected 24 or more hours apart. Non-maternal parents who are PUIs should not visit infants requiring ongoing hospital care until they are determined to be uninfected by molecular testing and/or clinical criteria. Non-maternal parents who develop symptoms of disease and are confirmed to have COVID-19 also must meet the requirements above before visiting infants in the NICU.
World Health Organization (WHO): Clinical management of severe acute respiratory infection (SARS) when COVID-19 disease is suspected Interim guidance, Caring for infants and mothers with COVID-19: IPC and breastfeeding, Section 12
(March 13, 2020, World Health Organization)
The World Health Organization recommends that birthing parents and infants “should be enabled to remain together and practise skin-to-skin contact, kangaroo mother care and to remain together and to practise rooming-in throughout the day and night, especially immediately after birth during establishment of breastfeeding, whether they or their infants have suspected, probable, or confirmed COVID-19.”
Studies and Research
Preliminary Findings of mRNA Covid-19 Vaccine Safety in Pregnant Persons
(April 21, 2021, New England Journal of Medicine)
Preliminary findings did not show obvious safety signals among pregnant persons who received mRNA Covid-19 vaccines. However, more longitudinal follow-up, including follow-up of large numbers of women vaccinated earlier in pregnancy, is necessary to inform maternal, pregnancy, and infant outcomes.
Covid-19 Pregnancy Issues and Antenatal Care. Overall Preterm and Cesarean Delivery Rates.
(UpToDate January 15, 2021)
Preterm birth and cesarean delivery rates have been increased in many studies but not all. Fever and hypoxemia may increase the risks for preterm labor, prelabor rupture of membranes, and abnormal fetal heart rate patterns, but preterm deliveries also occur in patients without severe respiratory disease. It appears that many third-trimester cases are electively delivered by cesarean because of a bias to intervene catalyzed by the belief that management of severe maternal respiratory disease would be improved by delivery; however, this hypothesis is unproven.
In a systematic review including over 11,000 pregnant and recently pregnant persons with suspected or confirmed COVID-19, 17 percent delivered before 37 weeks of gestation and 65 percent delivered by cesarean. Most preterm deliveries were iatrogenic; only 6 percent were spontaneous.
In the CDC COVID-19 Response Pregnancy and Infant Linked Outcomes Team report, the overall preterm delivery among 3913 live births to hospitalized patients with SARS-CoV-2 infection was 12.9 percent (which was higher than a national estimate of 10.2 percent) and was similar for symptomatic and asymptomatic mothers. The overall rate of cesarean delivery was 34 percent (rate in symptomatic and asymptomatic mothers: 34.6 and 31.6 percent, respectively), which is slightly above the cesarean delivery rate (31.9 percent) in the United States.
International Comparison of Guidelines for Managing Neonates at the Early Phase of the SARS-CoV-2 Pandemic
(June 15, 2020. Pediatric Research.)
At the start of the pandemic, lack of evidence-based guidance on the management of neonates born to SARS-CoV-2- positive mothers has led to ad hoc creation of national and local guidance. Compliance between collaborators to share and discuss protocols was excellent and may lead to more consensus on management, but future guidance should be built on high-level evidence, rather than expert consensus. This article describes the current state of national and local protocols for managing neonates born to SARS-CoV-2-positive mothers.
Maternal transmission of SARS‐COV‐2 to the neonate, and possible routes for such transmission: A systematic review and critical analysis
(June 12, 2020. BJOG: An International Journal of Obstetrics and Gynaecology.)
Early reports of COVID‐19 in pregnancy described management by caesarean, strict isolation of the neonate and formula feeding, is this practice justified? We included 49 studies which included 666 neonates and 655 women where information was provided on the mode of delivery and the infant’s infection status. 28/666 (4%) neonates had confirmed COVID‐19 infection postnatally. Of the 291 women who delivered vaginally, 8/292 (2.7%) neonates were positive. Of the 364 women who had a Caesarean birth, 20/374 (5.3%) neonates were positive. Of the 28 neonates with confirmed COVID‐19 infection, 7 were breast fed, 3 formula fed, 1 was given expressed breast milk and in 17 neonates the method of infant feeding was not reported.
Neonatal COVID‐19 infection is uncommon, uncommonly symptomatic, and the rate of infection is no greater when the baby is born vaginally, breastfed or allowed contact with the mother.
Identifying airborne transmission as the dominant route for the spread of COVID-19
(June 11, 2020.)
The authors show that airborne transmission is highly virulent and represents the dominant route to spread the disease. The current mitigation measures, such as social distancing, quarantine, and isolation implemented in the United States, are insufficient by themselves in protecting the public. The authors illustrate that the difference with and without mandated face covering represents the determinant in shaping the trends of the pandemic worldwide. The authors conclude that wearing face masks in public is the most effective way to prevent transmission between people.
What we know so far about Coronavirus Disease 2019 in children: A meta‐analysis of 551 laboratory‐confirmed cases
(June 10, 2020. Pediatric Pulmonology)
This systematic review included 46 studies reporting 551 pediatric patients with laboratory-confirmed COVID-19 between early January and late March 2020, of which 429 cases were from China, 11 cases from other Asian countries, and 110 cases from Europe (Italy and Spain). Eighty-seven percent of patients had household exposure to COVID-19 cases. The patients' age ranged from 1 day to 17.5 years old, and 216 were children under 5 years of age. At least seven cases were neonates aged up to 28 days.
Children of all ages can get COVID-19, although they appear to be affected less commonly than adults. Previously healthy children with COVID-19 usually have mild symptoms and good prognosis. Children with COVID-19 seem to have less severe disease and better prognosis than adults. Mild-to-moderate fever and cough are the most common symptoms, but much less frequently than that reported in adults, and 18% of patients may be asymptomatic. Of 551 pediatric cases with laboratory-confirmed COVID-19 included in this review, only nine had severe/critical disease. Six patients needed invasive mechanical ventilation, and one child died. All of these six patients had major underlying medical condition. The 10-month old child also had a major underlying medical condition called intussusception, experienced multiple organ failure, and died 4 weeks after admission.
Multi-system Inflammatory Syndrome in Children and Adolescents Temporally Related to COVID-19, Scientific Brief
(May 15, 2020. World Health Organization)
“As of 15 May 2020, more than 4 million confirmed cases of COVID-19, including more than 285 000 deaths have been reported to the World Health Organization (WHO). The risk of severe disease and death has been highest in older people and in persons with underlying noncommunicable diseases (NCDs), such as hypertension, cardiac disease, chronic lung disease and cancer. Limited data describe clinical manifestations of COVID-19 that are generally milder in children compared with adults, but also show that some children do require hospitalization and intensive care.
Relatively few cases of infants confirmed to have COVID-19 have been reported; those who are infected have experienced mild illness. Robust evidence associating underlying conditions with severe illness in children is still lacking. Among 345 children with laboratory-confirmed COVID-19 and complete information about underlying conditions, 23% had an underlying condition, with chronic lung disease (including asthma), cardiovascular disease, and immunosuppression most commonly reported.
Recently, however, reports from Europe and North America have described clusters of children and adolescents requiring admission to intensive care units with a multi-system inflammatory condition with some features similar to those of Kawasaki disease and toxic shock syndrome. Case reports and small series have described a presentation of acute illness accompanied by a hyper-inflammatory syndrome, leading to multi-organ failure and shock. Initial hypotheses are that this syndrome may be related to COVID-19 based on initial laboratory testing showing positive serology in a majority of patients. Children have been treated with anti-inflammatory treatment, including parenteral immunoglobulin and steroids.”
This condition is very rare.
COVID-19 in a 26-week Preterm Neonate, A Case Report
(May 7, 2020. The Lancet Child & Adolescent Health.)
This Case Report suggests that neonates infected with SARS-CoV-2 (even if extremely preterm) might not necessarily be susceptible to severe disease with clinically significant or major morbidity.