Based on current evidence, the Frequently Asked Questions below provide initial guidance for the management of infants born to mothers with confirmed and suspected COVID-19.
What is new in this update?
The first AAP neonatal guidance was provided on April 2, 2020, shortly after the onset of the global pandemic, when it was apparent that SARS-CoV-2 was very contagious and infected individuals could suffer severe mortality and morbidity. Since that time, published evidence as well as data provided to the National Registry for Surveillance and Epidemiology of Perinatal COVID-19 Infection and the Centers for Disease Control Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET) have better informed the risks of maternal and perinatal disease, resulting in revisions to the guidance. In this current update posted on July 20, 2022, guidance on infection prevention measures for hospital personnel and newborn testing is unchanged, and guidance on parent presence in the NICU is updated. We have updated statistics from the Perinatal COVID-19 Registry and include published evidence on neonatal SARS-CoV-2. We anticipate additional revision to this guidance as further evidence becomes available to inform newborn management.
What do we currently know about newborn risk for COVID-19?
The risk that a newborn tests positive for SARS-CoV-2 in the hours or days after birth to a mother with COVID-19 at the time of delivery is informed both by published case series and over 11,000 cases reported to date to the Perinatal COVID-19 Registry. Registry data collected April 2020 to March 2021 find that approximately 2% of infants born to pregnant persons who test positive for SARS-CoV-2 near the time of delivery have tested positive in the first 24-96 hours after birth. The rate at which infants tested positive was twice as high among infants born <37 weeks’ gestation.
Current evidence supports the highest risk of infection to newborns occurs when a mother has onset of COVID-19 near the time of delivery. CDC SET-NET data from 2020-2021 including 4038 infants born to pregnant persons who tested positive for COVID-19 during the birth hospitalization found that 5.6% of the newborns tested positive for the virus. It should be noted that there is not a clear risk distinction between maternal symptomatic or asymptomatic infection; rather, the timing of onset of maternal infection (and ability to transmit virus) is the most important factor for newborn infection.
Multiple national and international reports are now published describing outcomes of pregnant persons who test positive for COVID-19 at the time of delivery. Newborn death directly attributable to perinatal infection with SARS-CoV-2 is extremely rare in the United States. However, accumulating evidence suggests that maternal infection (primarily, but not exclusively, symptomatic infection at the time of delivery) is associated with increased risks of preterm birth, perinatal morbidity and other pregnancy complications. In addition, clinicians and families should be aware that there are published reports of infants requiring hospitalization before 1 month of age because of severe COVID-19 complications.
What precautions should I take to attend a delivery from a mother with COVID-19?
Don a gown and gloves and use either an N95 respirator and eye protection (goggles or face shield) or an air-purifying respirator that provides eye protection. This equipment protects against both maternal virus aerosols and potential newborn virus aerosols that resuscitation procedures (bag-mask ventilation, intubation, suctioning, oxygen at a flow >2 liters per minute [LPM], continuous positive airway pressure and/or mechanical ventilation) can generate.
Should we continue delayed-cord clamping and skin-to skin care practices?
Delayed cord clamping practices and skin-to-skin care in the delivery room should continue per usual center practice. Mothers with COVID-19 should use a mask while holding their baby.
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 can be mitigated by precautions 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.
- If noninfected 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.
- Health care workers should use gowns, gloves, N95 respirators, and eye protection (or air-purifying respirators) when caring for well infants when this care is provided in the same room as a mother with COVID-19. Health care workers may use N95 respirators at all times when caring for well infants at risk for SARS-CoV-2 infection.
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. 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 breastfeed 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.
What should I do if the infant requires intensive care?
Infants requiring neonatal intensive care and respiratory support optimally should be admitted to a single patient room with the potential for negative room pressure (or other air filtration system). If this type of room is not available or if multiple COVID-19-exposed infants must be cohorted, there should be at least 6 feet between infants and/or they should be placed in air temperature-controlled Isolettes. Isolette care does not provide the same environmental protection as use of negative pressure or air filtration but can provide an additional barrier against droplet transmission. Don gown and gloves and use either an N95 respirator and eye protection (or an air-purifying respirator) for care of infants requiring supplemental oxygen at a flow >2 LPM, continuous positive airway pressure, or mechanical ventilation.
For newborns who have been separated from an infected mother shortly after birth and admitted directly to the NICU, infection control precautions appropriate to the infant’s required respiratory care should be used until the infant has negative testing within the first 72 hours of age. This testing addresses the risk that the infant has acquired the virus by vertical transmission.
For newborns who have been rooming-in with an infected, presumed, or known contagious mother who subsequently require admission to the NICU, infection control precautions appropriate to the infant’s required respiratory care should be used until 10 days have passed since the last maternal-infant contact. Centers may determine testing based on their local resources; however, testing on admission to the NICU and at 5 to 7 days after last maternal contact is recommended. This testing will determine whether the infant has acquired the virus by horizontal transmission.
Should I test well newborns to determine whether they are infected with SARS-CoV-2?
If testing capacity is available, testing well newborns will facilitate plans for care after hospital discharge; will determine the need for ongoing precautions and use of personal protective equipment for care of hospitalized infants; and will continue to contribute to our understanding of viral transmission and newborn illness.
- Obtain a single swab of the nasopharynx and submit for a single test. The specifics of testing will depend on the requirements of local testing platforms.
- Healthy newborns should be tested at least once before hospital discharge. The test should be performed as close to the time of discharge as is practical, to provide the most accurate family guidance. However, to facilitate use of precautions and protective equipment, centers can opt to test first at approximately 24 hours of age and again at approximately 48 hours of age. Some infants with a negative test at 24 hours may have a positive test at a later time, particularly when rooming-in with a contagious mother.
- For infants cared for in the neonatal intensive care unit who are positive on their initial testing, consider follow-up testing at 48- to 72-hour intervals until 2 consecutive negative tests are obtained to establish that the infant has cleared the virus from mucosal sites. In most cases, this will not be necessary for infants discharged to home.
- For infants who require ongoing hospital care, caregivers should continue to use appropriate personal protective equipment until discharge, or until the infant has two consecutive negative tests collected ≥24 hours apart. This stringent PCR test-based approach may be optimal for sick and preterm newborns as the duration of shedding infectious virus has not been established for such infants.
What do I do when the infant is ready for hospital discharge?
Discharge newborns based on your center’s usual criteria. There is no specific benefit for infants born to mothers with COVID-19 that results from discharge earlier than usual center practice.
If infant SARS-CoV-2 testing is positive but the infant has no signs of COVID-19, plan for frequent outpatient follow-up (either by phone, telemedicine, or in-office) through 14 days after birth. During this period, take precautions to prevent spread from infant to caregivers by using masks, gloves (as available), and hand hygiene in the home environment and by health care staff in the outpatient office practice.
In most cases, the infant SARS-CoV-2 testing will be negative, and infants will be discharged to families in which other caregivers have been exposed to and may have acquired SARS-CoV-2 infection. Every effort should be taken to provide infection-prevention education to all caregivers of the infant, which includes not only written education but also verbal education in person, via telephone or virtually. Interpreter services should be utilized where appropriate. Although challenging in the home environment, mother should use a mask and hand hygiene when directly caring for the infant, until:
- she has been afebrile for 24 hours without use of antipyretics; at least 10 days have passed since symptoms first appeared; symptoms have improved; and
- in the case of asymptomatic pregnant persons identified only by obstetric screening tests, at least 10 days have passed since the positive test.
Other caregivers in the home should use masks and hand hygiene before and after contact with the infant until their status is resolved.
If the infant cannot be tested, then treat the infant as if virus-positive for a 10-day period of observation. Mother should still maintain precautions until she meets the criteria for noninfectivity as above.
When can I let the mother and her partner visit their newborn if the infant is in the NICU?
During the COVID-19 pandemic, most NICUs have appropriately limited parent presence and nonparent visitation. Such restrictions minimize the likelihood that vulnerable infants in the NICU will acquire an infection from a visitor with asymptomatic or symptomatic COVID-19. In addition, such policies protect the health and integrity of the specialized NICU workforce.
At this point in the pandemic, many people are vaccinated, but SARS-CoV-2 variants continue to circulate and infect both vaccinated and unvaccinated people. Parents and caregivers of NICU infants encounter 3 common scenarios: pregnant persons who test positive for COVID-19 on routine obstetric testing but are asymptomatic; mothers and partners who test positive for COVID-19 following symptoms or close exposure with another person with COVID-19; and mothers and partners with close exposures to COVID-19. Each scenario is further impacted by vaccination status. In the guidance below, “up-to-date” is defined as the individual having received all of their recommended doses of COVID-19 vaccine and 2 weeks have elapsed since their last dose.
- Pregnant persons who test positive for COVID-19 on routine obstetric testing but are asymptomatic. In these cases, the onset of infection is uncertain. PCR-based testing can detect viral nucleic acid when the tested person is no longer infectious. In the absence of symptoms or known exposure, those who test positive on routine obstetric screening and are up-to-date on COVID-19 vaccines should be excluded from the NICU for 5 days from the positive test (enter on day 6), as long as they remain asymptomatic. They should wear a mask for another 5 days from the positive test. Unvaccinated people should be excluded from the NICU for 10 days from the positive test (enter on day 11).
- Mothers and partners who test positive for COVID-19 following symptoms or close exposure to an infected person. Regardless of vaccination status, these people should not visit NICU infants while able to transmit SARS-CoV-2. Immunocompetent people may be considered noninfectious if (a) afebrile for 24 hours without use of antipyretics, (b) at least 10 days have passed since symptoms first appeared, and (c) symptoms have improved. People who are severely or critically ill with COVID-19 should not enter the NICU until at least 20 days have passed since symptoms first appeared or first positive test. For people who are severely immunocompromised and infected with SARS-CoV-2, we recommend consultation with your local infectious disease specialists for specific case management.
- Mothers and partners who have a close exposure to another person with COVID-19.
Asymptomatic people who are up-to-date on COVID-19 vaccines but have a close exposure to COVID-19 should not be excluded from the NICU if asymptomatic. Such people should wear a mask for 10 full days following last close contact and have SARS-CoV-2 testing at least 5 days following last close contact. If such people develop symptoms consistent with COVID-19 infection, they should obtain testing as soon as possible and not enter the NICU until their status is clarified. Mothers and partners who are not vaccinated against COVID-19 who then have a close contact to COVID-19 should be excluded from the NICU for 10 days from their last contact. Such people should have SARS-CoV-2 testing at least 5 days following last close contact or if symptoms develop.
Because recovered COVID-19 patients may have very prolonged (weeks to months) positive nucleic acid tests without evidence that such people remain infectious, centers should not require infected parents to have negative PCR-based testing before entry into the NICU.
Is there any advantage to early hospital discharge for infants born to COVID-negative mothers?
No. Earlier discharge than the usual center practice with the intent to reduce risk of COVID-19 infection provides no advantage to the newborn or family. An earlier discharge may place additional burdens on families to access, and on outpatient pediatric offices to provide, recommended newborn care, screenings, and outpatient follow-up. In-person post-discharge visits are the preferred means to provide timely newborn screening, bilirubin testing feeding and weight assessments.
Interim Guidance Disclaimer: The COVID-19 clinical interim guidance provided here has been updated based on current evidence and information available at the time of publishing. Guidance will be regularly reviewed with regards to the evolving nature of the pandemic and emerging evidence. All interim guidance will be presumed to expire on December 31, 2022 unless otherwise specified.
American Academy of Pediatrics