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 highly contagious and infected individuals could suffer severe mortality and morbidity. Since that time, data provided to the National Registry for Surveillance and Epidemiology of Perinatal COVID-19 Infection and published evidence from the Centers for Disease Control and Prevention (CDC) Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET) as well as the CDC Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET) have better informed the risks of maternal and perinatal disease, resulting in revisions to the guidance. In this current update posted on November 10, 2022, guidance on infection prevention measures for hospital personnel and newborn testing is unchanged, and guidance on parent presence in the NICU is updated. Statistics from the Perinatal COVID-19 Registry and SET-NET and COVID-NET data on neonatal and young infant SARS-CoV-2 are updated. Additional revision to this guidance is anticipated as further evidence becomes available to inform newborn management.
Note: Throughout this section, “transmission-based precautions” for health care workers are defined as use of gown and gloves and use of either an N95 respirator and eye protection (goggles or face shield) or an air-purifying respirator that provides eye protection.
What do we currently know about newborn risk for COVID-19?
The risk that a newborn infant 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 more than 11,000 cases reported to date to the Perinatal COVID-19 Registry. Registry data collected from April 2020 to March 2021 (prior to widespread availability of COVID-19 vaccines) revealed that 2.2% 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 to 96 hours after birth. The rate at which infants tested positive was twice as high among infants born at <37 weeks’ gestation.
Current evidence indicates that the highest risk of infection to newborn infants 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 infants tested positive for the virus. In the Perinatal COVID-19 Registry, the rate of newborn infection was as high as 13.6% in cases of maternal illness onset at the time of childbirth. It should be noted, however, 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. In contrast, accumulating evidence suggests that severe maternal infection is associated with increased risks of preterm birth, perinatal morbidity, and other pregnancy complications. CDC COVID-Net data from 2020-2022 demonstrate that infants <2 months of age constitute 25% of all children <4 years of age hospitalized because of COVID-19.
What precautions should I take to attend a delivery from a mother with COVID-19?
Transmission-based precautions should be used. 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 delayed-cord clamping and skin-to skin care practices be discontinued?
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 face mask while holding their infant.
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 newborn infants from maternal infectious respiratory secretions. Mothers and well newborn infants should be cared for using usual center practice, including rooming-in (couplet care). A mother who is significantly 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 infant or to have the infant cared for by noninfected caregivers in mother’s room.
Currently, the AAP recommends the following for care of mothers with confirmed or suspected COVID-19 and their well newborn infants:
- Mothers and newborn infants may room-in according to usual center practice.
- During the birth hospitalization, the mother should maintain a reasonable distance from the infant when possible and wear a face mask. When a mother provides hands-on care to the infant, the mother should wear a mask and perform hand hygiene.
- If noninfected partners or other family members are present during the birth hospitalization, they should use face masks and hand hygiene when providing hands-on care to the infant.
- Health care workers should use transmission-based precautions when caring for well infants when this care is provided in the same room as a mother with COVID-19. Health care workers may choose to use transmission-based precautions 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 infant, she may express breast milk to be fed to the infant by other uninfected caregivers.
- Mothers of infants in the NICU 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 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. Health care personnel should use transmission-based precautions for care of infants requiring supplemental oxygen at a flow >2 LPM, continuous positive airway pressure, or mechanical ventilation.
For newborn infants 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 will determine whether the infant has acquired the virus by vertical transmission.
For newborn infants 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 well newborn infants be tested to determine whether they are infected with SARS-CoV-2?
If testing capacity is available, testing well newborn infants by PCR will facilitate plans for care after hospital discharge, determine the need for ongoing precautions and use of personal protective equipment for care of hospitalized infants, and continue to contribute to our understanding of viral transmission and newborn illness.
- Obtain a single swab specimen from the nasopharynx and submit it for a single PCR test. The specifics of testing will depend on the requirements of local testing platforms.
- Healthy newborn infants 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 transmission-based precautions, centers can opt to test first at approximately 24 hours of age and again at approximately 48 to 72 hours of age. Some infants with a negative test result at 24 hours may have a positive test result at a later time, particularly when rooming-in with a contagious mother.
- For infants with ongoing care in the NICU who have a positive result 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.
- For infants who require ongoing hospital care, caregivers should continue to use appropriate transmission-based precautions until discharge or until the infant has 2 consecutive negative test results collected ≥24 hours apart. This stringent PCR test-based approach should be reserved for sick and preterm newborn infants, because the duration of shedding infectious virus has not been established for such infants.
What should happen when the infant is ready for hospital discharge?
Newborn infants should be discharged based on the center’s usual criteria. There is no specific benefit for infants born to mothers with COVID-19 being discharged earlier than usual center practice.
If the infant’s SARS-CoV-2 test result 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 face masks and hand hygiene in the home environment. Health care staff should use transmission-based precautions (or at least face masks and hand hygiene) in the outpatient office practice.
In most cases, the infant’s SARS-CoV-2 test result 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 used when appropriate. Although challenging in the home environment, the mother should use a face mask and hand hygiene when directly caring for the infant, until:
- the mother 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 an asymptomatic pregnant person identified only by obstetric screening tests, at least 10 days have passed since the positive test.
Other caregivers in the home should use face 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 SARS-CoV-2 positive for a 10-day period of observation. The mother should still maintain precautions until she meets the criteria for non-infectivity as above.
When can 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. Three common scenarios may occur related to parents and caregivers of NICU infants: pregnant persons who test positive for COVID-19 on routine obstetric testing but are asymptomatic; mothers, partners, and support persons who test positive for COVID-19 after becoming symptomatic or having close exposure with another person with COVID-19; and mothers and partners with close exposures to COVID-19.
- 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 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 face mask on days 6 through 10 after positive test.
- Mothers and partners who test positive for COVID-19 by PCR-based or antigen-based testing following symptoms or close exposure to an infected person. 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. People who are severely immunocompromised and infected with SARS-CoV-2 should consult with 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 have a close exposure to COVID-19 should not be excluded from the NICU if asymptomatic. Such people should wear a face 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.
Because recovered COVID-19 patients may have very prolonged (weeks to months) positive nucleic acid test results 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 infant 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 postdischarge visits are the preferred means to provide timely newborn screening, bilirubin testing, and 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.
American Academy of Pediatrics