[2022] COVID-19: If I test positive or have symptoms, will I be separated from my baby after birth? [wc]

Updated 1/4/2022

When you arrive at the hospital in labor, you will most likely be screened for COVID-19. If you test positive, or if you have symptoms that suggest you might be infected, then you and your clinical team will have to decide together:

Is it better overall for you and your newborn to room together, or is it better for you to be in separate rooms?

Guidance from major health organizations has evolved over the course of the pandemic. To help you think about what you might do if you are faced with this decision, here are recommendations from:

• the Illinois Department of Public Health (“IDPH”)
• the Centers for Disease Control (“CDC”)
• the American College of Obstetricians and Gynecologists (“ACOG”)
• the American Academy of Pediatricians (“AAP”), and
• the World Health Organization (“WHO”).

All of these leading health organizations now support covid-positive mothers who wish to room-in with their newborns under most circumstances. 

The most important thing to keep in mind is that this decision is ultimately up to you. As the American College of Obstetricians and Gynecologists (“ACOG”) describes the decision-making process in their publication, “Coronavirus (COVID-19), Pregnancy, and Breastfeeding: A Message for Patients”:

Talk with your health care team about the options at your hospital or birth center well before your due date. Together you can discuss what you think is right for you and your baby. Be sure to talk about the best ways to

• reduce the risk of infection for your baby
• support the long-term health of you and your baby
• help you start breastfeeding if desired

[emphasis added]

 

IDPH: “Children & Pregnant Women Guidance“

Guidance from the Illinois Department of Public Health supports women who are positive for COVID-19 and who want to keep their babies with them, touch and hold them, and breastfeed:

In August 2020, the CDC updated its guidance on whether a COVID-positive mother and her newborn should be separated. That guidance has not changed since.

The CDC

• recommends rooming in, and
• explicitly acknowledges that the decision is ultimately up to the family

In addition, the CDC continues to support breastfeeding by mothers who are COVID-positive.

The CDC supports rooming in

The updated CDC guidance on “Mother/neonatal contact” now emphasizes the benefits of mother-baby contact and notes that the risk of transmission appears to be low and does NOT appear to increase when mother and baby room together.

• “Early and close contact between the mother and neonate has many well-established benefits.”
• “The ideal setting for care of a healthy, term newborn while in the hospital is in the mother’s room, commonly called ‘rooming-in’.”
• “Current evidence suggests the risk of a neonate acquiring SARS-CoV-2 from its mother is low. Further, data suggests that there is no difference in risk of SARS-CoV-2 infection to the neonate whether a neonate is cared for in a separate room or remains in the mother’s room.”

The CDC emphasizes shared decision-making and recognizes “maternity autonomy”

Addressing the decision-making process, the updated CDC guidance states:

“Ideally, each mother and her healthcare providers should discuss whether she would like the neonate to be cared for in her room or a separate location if she is suspected or confirmed of having COVID-19, weighing the considerations listed below. It’s easiest to begin this conversation during prenatal care and continue it through the intrapartum period. Healthcare providers should respect maternal autonomy in the medical decision-making process.”

According to the CDC, the considerations that healthcare providers should discuss with each family facing this decision include:

• Mothers who room-in with their infants can more easily learn and respond to their feeding cues, which helps establish breastfeeding. Breastfeeding reduces morbidity and mortality for both mothers and their infants. Mothers who choose to breastfeed should take measures, including wearing a mask and practicing hand hygiene, to minimize the risk of virus transmission while feeding. Additional information for healthcare providers on breastfeeding in the context of COVID-19 is available.
• Mother-infant bonding is facilitated by keeping the neonate with its mother.
• Rooming-in promotes family-centered care and can allow for parent education about newborn care and infection prevention and control practices.
• Mothers with suspected or confirmed SARS-CoV-2 infection should not be considered as posing a potential risk of virus transmission to their neonates if they have met the criteria for discontinuing isolation and precautions:
  • At least 10 days have passed since their symptoms first appeared (up to 20 days if they have more severe to critical illness or are severely immunocompromised), and
  • At least 24 hours have passed since their last fever without the use of antipyretics, and
  • Their other symptoms have improved.
• Mothers who have not met these criteria may choose to temporarily separate from their neonates in effort to reduce the risk of virus transmission. However, if after discharge they will not be able to maintain separation from their neonate until they meet the criteria, it is unclear whether temporary separation while in the hospital would ultimately prevent SARS-CoV-2 transmission to the neonate, given the potential for exposure from the mother after discharge.
• Separation may be necessary for mothers who are too ill to care for their infants or who need higher levels of care.
• Separation may be necessary for neonates at higher risk for severe illness (e.g., preterm infants, infants with underlying medical conditions, infants needing higher levels of care).
• Separation in order to reduce the risk of transmission from a mother with suspected or confirmed SARS-CoV-2 to her neonate may not be necessary if the neonate tests positive for SARS-CoV-2.

The CDC details measures to minimize risk of transmission

If the neonate remains in the mother’s room, measures that can be taken to minimize the risk of transmission from a mother with suspected or confirmed COVID-19  to her neonate include:

• Mothers should wear a mask and practice hand hygiene during all contact with their neonates. Of note, plastic infant face shields are not recommended and masks should not be placed on neonates or children younger than 2 years of age.

• Engineering controls, such as maintaining a physical distance of >6 feet between the mother and neonate or placing the neonate in an incubator, should be used when feasible. If the infant is kept in an incubator, it is important to educate the mother and other caregivers, including hospital personnel, on proper use (i.e., latching doors) in order to prevent newborn falls.

The CDC supports breastfeeding by COVID-positive mothers

On June 2021, the CDC updated its additional, specific guidance for COVID positive mothers who are considering breastfeeding. The “key points” from that guidance as summarized by the CDC are:

• Breast milk is the best source of nutrition for most infants, and it provides protection against many illnesses. There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended.
• People without suspected or confirmed COVID-19 and who have not been in close contact with someone who has COVID-19, or who have been fully vaccinated for COVID-19 do not need to take special precautions when feeding at the breast or expressing milk. All breastfeeding people regardless of COVID-19 status who are using breast pumps should be educated about CDC information on how to properly clean and sanitize their breast pump.

How to Protect the Breastfed Child

The following information can be used to counsel breastfeeding persons on precautions to take while feeding at the breast, expressing milk, or feeding from a bottle when the breastfeeding person

• has suspected or confirmed COVID-19 or
• has been in close contact with someone who has COVID-19 and is not fully vaccinated.

During the COVID-19 pandemic, consider providing additional information on isolation and quarantine when counseling people with specific living situations, such as those living in close quarters or living in shared housing.

Isolation and quarantine

• The breastfeeding person should follow information on quarantine or isolation.
• A child being breastfed by someone with suspected or confirmed COVID-19 should be considered as a close contact of a person with COVID-19, and should be quarantined for the duration of the lactating parent’s recommended period of isolation and during their own quarantine thereafter.

Precautions while feeding at the breast, expressing milk, or feeding from a bottle

• Breastfeeding people should follow these precautions during their recommended period of isolation:
  • Wash their hands using soap and water before touching their child or expressing breast milk either by hand expression or with a breast pump. If soap and water are not available, use hand sanitizer with at least 60% alcohol.
  • Wear a mask when they are less than 6 feet from the child (including when feeding at the breast or feeding from a bottle) and when expressing breast milk
  • Clean and sanitize breast pumps and all infant feeding items.
• Any healthy caregiver, preferably one who is fully vaccinated against COVID-19 and not at increased risk for severe illness from COVID-19, may feed expressed breast milk to the child. If this person is not vaccinated and is living in the same house or has been in contact with the breastfeeding person, they should wear a mask while feeding the child for the duration of the lactating parent’s recommended period of isolation and during their own quarantine thereafter.
• See more information on breastfeeding neonates in the hospital setting when the lactating parent has suspected or confirmed COVID-19.

Other considerations

• Some people with suspected or confirmed COVID-19 may desire to breastfeed their child, but they may be unable to or choose not to during their COVID-19 illness. One reason may be that they are unable to access appropriate support. Healthcare professionals may refer patients to professional lactation support as needed. Reestablishment of lactation (or relactation) may be possible for some.
• Breastfeeding people should be counseled to inform their child’s healthcare professional that their child has had close contact with a person suspected or confirmed to have COVID-19 prior to any in-person healthcare visits or if the child develops symptoms of COVID-19.

How to Protect the Breastfeeding Person

The following information can be used to counsel breastfeeding dyads on precautions to take while feeding at the breast, expressing milk, or feeding from a bottle when the breastfed child

• has suspected or confirmed COVID-19 or
• has been in close contact with someone who has COVID-19 and the breastfeeding person is not fully vaccinated.

During the COVID-19 pandemic, consider providing additional information on isolation and quarantine when counseling people with specific living situations, such as those living in close quarters or living in shared housing.

CDC recommends that everyone 12 years of age and older should get a COVID-19 vaccination to help protect against COVID-19. More information about COVID-19 vaccines for breastfeeding/lactating persons can be found here https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html

Isolation and quarantine

• The breastfed child with suspected or confirmed COVID-19 should follow information on quarantine or isolation.
• People who are breastfeeding a child with suspected or confirmed COVID-19 should be considered as a close contact of a person with COVID-19, and should be quarantined for the duration of the breastfeeding child’s recommended period of isolation and during their own quarantine thereafter.

Precautions while feeding at the breast, expressing milk, or feeding from a bottle

• • Because of the danger of suffocation, masks should NOT be put on children younger than 2 years.
  • To minimize possible exposure, breastfeeding people may choose to take precautions as recommended above for those with suspected or confirmed COVID-19 while feeding at the breast, expressing milk, or feeding from a bottle. This includes wearing a mask during any close contact (i.e., less than 6 feet) with the child and cleaning their hands frequently (i.e., before and after touching their child).
  • Recently pregnant people (for at least 42 days following end of pregnancy) are at increased risk for severe COVID-19 illness. Healthcare professionals may counsel the breastfeeding person on risks and benefits of continuing to feed at the breast during the child’s COVID-19 illness.

The American College of Obstetricians and Gynecologists (ACOG)

ACOG updated its publication, “Coronavirus (COVID-19), Pregnancy, and Breastfeeding: A Message for Patients” on December 3rd, 2021. ACOG continues to support COVID-positive mothers who wish to room in and/or breastfeed their newborns, noting that separation in the hospital does not appear to reduce the risk of passing COVID-19 to your baby. ACOG emphasizes that the decision whether to separate from your baby is up to you:

There are many benefits to having your baby stay in the same room as you after delivery, even if you have COVID-19. For example, rooming together may help you bond with your baby and help you start breastfeeding if desired.

You also may choose for your baby to stay separated from you, such as in the hospital nursery. But current reports suggest that the risk of a baby getting COVID-19 does not change based on whether the baby stays in the mother’s room or in a separate room. (See How can I avoid passing COVID-19 to my baby?) If you room together, the baby’s crib may be kept at least 6 feet away from you. Some facilities use clear plastic cribs that are enclosed and keep an even temperature.

Staying in a separate room may be encouraged if you are very sick or your baby is at a high risk of getting very sick. If you choose to be separated and you plan to breastfeed, you can ask for a breast pump and use it to express (pump) milk. This will allow someone who is not sick to bottle-feed breast milk to your baby. Pumping also may help you maintain your milk supply for when you begin breastfeeding.

Talk with your health care team about the options at your hospital or birth center well before your due date. Together you can discuss what you think is right for you and your baby. Be sure to talk about the best ways to

• reduce the risk of infection for your baby
• support the long-term health of you and your baby
• help you start breastfeeding if desired

The American Academy of Pediatrics (AAP)

The AAP originally recommended separation of a COVID positive mother from her newborn, but has now updated its position to support keeping mother and baby together. Like the CDC and ACOG, the AAP notes that there is no evidence that separation of mother and baby in the hospital reduces the risk of transmission to the baby.

In its publication, updated Dec 1, 2021, “FAQs: Management of Infants Born to Mothers with Suspected or Confirmed Covid-19″, the AAP states:

Can mother and well newborns room-in?

Yes. The evidence to date suggests that the risk of the newborn acquiring infection during the birth hospitalization is low when precautions are consistently taken to protect newborns from maternal infectious respiratory secretions. Mothers and well newborns should be cared for using usual center practice, including rooming-in (couplet care). A mother who is acutely ill with COVID-19 may not be able to care for her infant in a safe way. In this situation, it may be appropriate to temporarily separate mother and newborn or to have the newborn cared for by non-infected caregivers in mother’s room.

Currently we recommend the following for care of mothers with confirmed or suspected COVID-19 and their well newborns:

• Mothers and newborns may room-in according to usual center practice.
• During the birth hospitalization, the mother should maintain a reasonable distance from her infant when possible. When a mother provides hands-on care to her newborn, she should wear a mask and perform hand-hygiene.
• Healthcare workers should use gowns, gloves, N95 respirators and eye protection (or air-purifying respirators) when providing care for well infants, when this care is provided in the same room as a mother with COVID-19. When supplies are adequate, healthcare workers may use N95 respirators at all times when caring for well infants at risk for SARS-CoV-2 infection; standard procedural masks may be used if necessary.
• If non-infected partners or other family members are present during the birth hospitalization, they should use masks and hand hygiene when providing hands-on care to the infant.

Can the infant breastfeed?

Yes. The AAP strongly supports breastfeeding as the best choice for infant feeding. Several published studies have detected SARS-CoV-2 nucleic acid in breast milk. Currently, however, viable infectious virus has not been detected in breast milk. One study demonstrated that pasteurization methods (such as those used to prepare donor milk) inactivate SARS-CoV-2. Several recent studies have found antibody in human milk to specific SARS-CoV-2 antigens. Both IgA and IgG antibodies have been detected in breast milk after both maternal infection and maternal vaccination against SARS-CoV-2. Given these findings, direct breastfeeding is encouraged at this time.

• Infected mothers should perform hand hygiene before breastfeeding and wear a mask during breastfeeding.
• If an infected mother chooses not to nurse her newborn, she may express breast milk after appropriate hand hygiene, and this may be fed to the infant by other uninfected caregivers.
• Mothers of NICU infants may express breast milk for their infants during any time that their infection status prohibits their presence in the NICU. Centers should make arrangements to receive this milk from mothers until they are able to enter the NICU.

 

The WHO Guidance: Q&A on COVID-19, pregnancy, childbirth and breastfeeding

The WHO has not directly addressed the question of whether you should room in with your baby if you have or might have COVID-19. However, the WHO has strongly advocated in favor of mothers who wish to breastfeed or have skin-to-skin contact with their babies, even if positive for the virus. 

The World Health Organization’s Q & A on COVID-19, pregnancy, childbirth, and breastfeeding (dated September 2nd) states:

Can I touch and hold my newborn baby if I have COVID-19?

Yes. Close contact and early, exclusive breastfeeding helps a baby to thrive. You should be supported to

• Breastfeed safely, with good respiratory hygiene; 
• Hold your newborn skin-to-skin, and
• Share a room with your baby

You should wash your hands before and after touching your baby, and keep all surfaces clean. Mothers with symptoms of COVID-19 are advised to wear a medical mask, during any contact with the baby.

Summing it up

Leading health organizations at the state, national and international level are now aligned in supporting rooming in for COVID-positive mothers and their babies in most circumstances.  Several organizations emphasize that current evidence does not suggest a greater risk of infecting your baby if you room in. Most importantly, THE DECISION IS UP TO YOU.

Your clinical team should share with you the medical evidence about risks and benefits of rooming in with your baby if you are COVID-19 positive in light of all the specifics of your particular situation.  You should share with them your preferences and priorities as a family for the care of your baby. By pooling information, you and your clinical team can make the best decision about what is right in your case. The shared goal should be to reach a decision that feels right to you in light of all considerations, medical and personal.