The first article, published in volume 29, issue 4 of the British Journal of Midwifery, in this two-part series focusing on the care implications of COVID-19 in maternal health addressed the effect on the mother along with subsequent issues relating to parenting and support. This second article now turns to newborn care.
The world is still learning the specifics of how SARS-CoV-2 is spread, and this is a particularly important area of knowledge in the field of maternal and neonatal care (Green et al, 2020a). While it has been shown that people with SARS-CoV-2 symptoms spread the disease, evidence is emerging that asymptomatic patients should not be underestimated (Heneghan et al, 2020; de Rose et al, 2020). Transmission of SARS-CoV-2 mainly occurs through droplets and aerosols but it can also be transferred through skin contact, faecal-oral transmission and ocular surface contact (de Rose et al, 2020). The evidence on maternal-infant vertical transmission, however, is still unclear. Pregnant women may be more susceptible to the virus (Favre et al, 2020) as evidenced by Alfaraj et al's (2019) analysis from previous viral SARS-CoV and MERS-CoV outbreaks, suggesting a greater risk of adverse outcomes. It is not known definitively whether a pregnant woman with SARS-CoV-2 could pass the infection to her fetus or baby during pregnancy or delivery. Currently, the emerging evidence to support vertical transmission of SARS-CoV-2 during pregnancy remains low (Knight et al, 2020) and the existing data shows a low incidence of infection in amniotic fluid, cord blood, neonatal throat swab, placental tissue and breastmilk samples (Yang et al, 2020a).
COVID-19 must be taken seriously not only because of the potential for disease transmission but on the ramifications of social distancing policies on families and health professionals. Moreover, in the light of the current lack of literature on SARS-CoV-2 in midwifery, there is a need to address these significant issues faced globally and contribute to the emerging body of evidence during this pandemic. The aim of this paper is to explore the current and emerging literature and draw out essential implications for practice relating to newborn care, contributing a midwifery perspective to the emerging body of evidence in this unprecedented time.
Method
As for part 1, an integrative review methodology was utilised for this paper to facilitate a comprehensive understanding of SARS-CoV-2 infection in babies. The literature was gathered using Arksey and O'Malley's (2005) five-step framework and Levac et al's (2010) method of synthesising health evidence. COVID-19 has only been seen in 2020; therefore, recent literature was easily identified using the terms:
- SARS-CoV-2 in pregnancy AND outcomes (8410)
- SARS-CoV-2 in babies/neonates AND outcomes (1670)
The search was then limited to:
- Full text in English (many of the earlier publications report results of women and babies in China because this is where COVID-19 is believed to have started)
- Pregnancy in women with SARS-CoV-2 and the disease process
- Guidelines for women with suspected SARS-CoV-2 infection
- Articles about possible intrauterine transmission
- Articles about possible transmission during labour and delivery
- Neonatal SARS-CoV-2 case reports.
Updates from the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have also been utilised to ensure that any recommendations comply with current best evidence and practice.
Findings
The emerging themes for discussion in the context of COVID-19 were physiological differences between the newborn baby and adult, neonatal management, including preterm labour and delivery, newborn resuscitation, investigations, care of the newborn, the importance of human milk and breastfeeding, and the implications of COVID-19 restrictions.
Physiological differences between the newborn and adult
Research on neonates shows that under normal circumstances, the immaturity of the respiratory and immune systems would be a major risk factor for SARS-CoV-2 respiratory disease (Mandal, 2020). The respiratory anatomy and physiology of the neonate differs from older children and explains why neonates can become acutely ill when they have a respiratory illness (Saikia and Mahanta, 2019). In relation to COVID-19 however, a different picture has emerged.
In adults, the pathophysiology of the virus and how it affects the human body is now starting to be known. SARS-CoV-2 leads to an overproduction of immune cells and their activating compounds, cytokines. A surge of activated immune cells into the lungs occurs (Coperchini et al, 2020) known as the cytokine ‘storm’, a cascading process whereby the immune system overreacts to an infection. The resulting lung inflammation causes direct lung tissue damage, recruitment of neutrophils to tissues, and other pro-inflammatory effects leading to acute respiratory distress syndrome (Mehta et al, 2020). In babies however, it is thought that there may be a link between the naïve newborn immune system and a decreased risk of this cytokine ‘storm’ in SARS-CoV-2. Natural killer cells may play a part in this; these are among the earliest cellular responders and defence against most viral infections (Strauss-Albee et al, 2017) and serve as a bridge between innate immunity and adaptive immunity and release a variety of cytokines (Lee and Lin, 2013).
In addition, SARS-CoV-2 directly infects cells through the ACE2 receptor cells which is expressed in the organs, including the lungs (Sriram et al, 2020). The ACE2 receptor cells in children's lungs are expressed less than in adult lungs which may explain why the infection affects children less severely (de Rose et al, 2020). Furthermore, a recent study by Pique-Regi et al (2020) identified that placental membranes lack the messenger RNA molecule required to manufacture the ACE2 receptor, the main cell surface receptor used by the SARS-CoV-2 virus to cause infection. According to these researchers, this may be one reason why there is little fetal infection from SARS-CoV-2-positive mothers, and subsequent newborn infection.
Explaining the physiological differences in the newborn may enhance understanding of why the rates of infection are so much lower than the adult population. It is also important to consider specific aspects of neonatal care in the context of COVID-19 to which the discussion will now turn, drawing on new information emerging from the current literature.
Premature labour and delivery
According to Carvalho et al (2020), 47% of SARS-CoV-2-positive mothers experienced a premature delivery. Antenatal steroids (ANS), such as dexamethasone, are administered to the mother in preterm labour to mature the lungs and lessen the incidence of Respiratory Distress Syndrome (RDS) in the premature neonate. Use of steroids prevents death and improves long-term outcomes across the range of prematurity (Russell et al, 2020). In the initial course of SARS-CoV-2 infection, concern was raised as to whether ANS would place vulnerable preterm neonates more at risk of developing SARS-CoV-2 due to their immunosuppressive action (Chandrasekharan et al, 2020). Recently however, the RECOVERY trial in the UK has shown promising results with dexamethasone in the management of adults in acute stages of SARS-CoV-2 (University of Oxford, 2020). Dexamethasone is used in many respiratory conditions associated with inflammatory response. It is effective in suppressing the aforementioned cytokine storm associated with SARS-CoV-2 infection. To date, there have been no studies focusing on antenatal dexamethasone and severity of SARS-CoV-2 in the preterm neonate. However, the results of the RECOVERY trial raise the question of whether maternal dexamethasone for preterm labour could be beneficial in neonatal SARS-CoV-2 infections. It is noteworthy that corticosteroids have shown no proven benefit and/or harm in other similar pandemic viral infections such as SARS, MERS and influenza (Russell et al, 2020).
Neonatal resuscitation
Premature birth often requires active resuscitation with bag and mask ventilation and endotracheal intubation. Interim guidelines from the American Heart Association have been developed to guide healthcare workers in neonatal resuscitation (Edelson et al, 2020). Simultaneously, individual countries and health authorities have also developed specific guidelines in the care of mothers and babies during the pandemic (Australian Queensland Health Clinical Guidelines, 2020; UK Resuscitation Council, 2020). Currently, the advice is a balance between providing for the immediate needs of the mother and newborn, and the safety of the rescuer and healthcare personnel.
Neonatal cardiopulmonary resuscitation poses an increased risk of exposure to SARS-CoV-2 for the healthcare worker for several reasons (Edelson et al, 2020). Administering positive pressure ventilation and chest compressions may generate aerosols containing coronavirus particles. In performing resuscitation, rescuers are required to work closely to one another and in emergency situations, there may be inadvertent lapses in infection-control practices. The advice for all healthcare workers is to protect themselves and their colleagues from unnecessary exposure to SARS-CoV-2 by taking contact and droplet precautions (Edelson et al, 2020).
Where there is a high risk of aerosolised coronavirus particles, healthcare workers are required to don personal protective equipment (PPE) and only essential personnel be present at the resuscitation (Chandrasekharan et al, 2020). Initial newborn care such as providing tactile stimulation through drying, placement into plastic wrap and application of pulse oximetry are unlikely to be aerosol producing procedures and unnecessary suction of the airway after delivery should not be performed (Edelson et al, 2020). All newborns requiring active resuscitation should be placed under a radiant heat source in or near the delivery room to minimise potential environmental exposure (Carvalho et al, 2020).
All at-risk deliveries require personnel who have the expertise to undertake neonatal resuscitation. For neonatal airway intubation, the person most likely to succeed on first attempt should be present; video laryngoscopy is recommended to reduce the rescuer's exposure to aerosolised viral particles. If intubation is delayed, a laryngeal mask should be considered. Whether ventilating via bag and mask/T-piece or closed-circuit ventilator, the exhaled gasses should have a high efficiency particulate air (HEPA) filter. Airway suctioning procedures pose one of the greatest risks to aerosolised viral particles and once a closed-circuit ventilation system is established, a closed suction system should also be employed (Chandrasekharan et al, 2020; Edelson et al, 2020).
Medications where possible are to be administered through the umbilical venous route. However, instillation of surfactant can only be administered via the endotracheal route. This procedure is at a high risk of generating aerosolised particles and therefore the administrator requires PPE with full-face clear plastic visor (Chandrasekharan et al, 2020; Edelson et al, 2020). The Queensland Clinical Guidelines (2020) in Australia, for example, recommend the less invasive surfactant administration method to reduce the risk to the administrator.
Unwell neonates will require a heated closed incubator for transfer to the neonatal nursery and continued to be nursed within this, with full droplet precautions in a negative pressure isolation room (Chandrasekharan et al, 2020). In cases where neonatal transport is required following birth, strict droplet and contact precautions along with isolation procedures are to be employed throughout the transport, and both the transport incubator and the ambulance should be extensively disinfected post transfer (de Rose et al, 2020).
Investigations for SARS-CoV-2 in the newborn
In the limited reports highlighting neonates with SARS-CoV-2, the route of transmission is unclear and new case studies are emerging daily. One recent study from Vivanti et al (2020) provides evidence of a transplacental transmission of SARS-CoV-2 infection in a newborn. Due to this uncertainty, it is therefore recommended that all newborns delivered from SARS-CoV-2-positive mothers are thoroughly investigated for SARS-CoV-2. The initial investigations at birth should be nasopharyngeal and oropharyngeal swab using a single swab for both sites. There is no need to repeat investigations if the baby remains well (Chandrasekharan et al, 2020; Mimouni et al, 2020). Further investigations may be required if a neonate becomes unwell (with fever or acute respiratory illness) and is in contact with a SARS-CoV-2-positive caregiver or due to transmission through close environmental contacts.
If a neonate has symptoms of congenital pneumonia after delivery from a SARS-CoV-2-positive mother, then vertical transmission is a possibility and is an indication for further testing. In these situations, repeat swabs or endotracheal aspirates if intubated may be necessary. Further investigative recommendations include amniotic fluid, cord blood, placental swabs, genital swabs, as well as neonatal throat and nasopharyngeal swabs (Kallem and Sharma, 2020). Carvalho et al (2020) recommend neonates with positive polymerase chain reaction for SARS-CoV-2 tests should be repeated every 48–72 hours until two consecutive negative results are obtained.
Care of the newborn and mother
For the vigorous newborn, delayed cord clamping to allow for redistribution of placental blood to the neonate and maintain preload can be employed (Chandrasekharan et al, 2020). If both mother and baby are well, there is no need to separate a SARS-CoV-2-positive mother from her baby (Queensland Clinical Guidelines, 2020; Royal College of Paediatricians and Child Health, 2020). Likewise, if the mother and baby are well, then skin-to-skin and breastfeeding should be encouraged as benefits far outweigh any potential harms (WHO, 2020a). It is recommended that all newborn babies from mothers with suspected or confirmed SARS-CoV-2 in the 14 days prior to delivery should be transported in a heated closed incubator to the mother-baby isolation room (Carvalho et al, 2020; Edelson et al, 2020). Parents need to be fully informed on droplet precautions and strict hand hygiene with feeding and nappy changing (Carvalho et al, 2020).
Chandrasekharan et al (2020) recommend bathing the newborn immediately after birth to remove any potentially harmful virus from the skin if the mother is SARS-CoV-2-positive. In previous outbreaks of Ebola and MERS, vaccination routines were disrupted resulting in declining immunisation coverage (Semaan et al, 2020). It is imperative, particularly for low-resource countries, that all routine vaccinations for hepatitis B and vitamin K injections be administered and other routine newborn screening, hearing and cardiac tests are undertaken as usual in order to reduce the possible future preventable disease burden (Carvalho et al, 2020).
If a neonate becomes unwell and requires neonatal unit admission, they should be nursed with droplet precautions in a closed incubator and management is directed by the presenting signs (Carvalho et al, 2020). The acutely ill newborn will need to be transferred to an appropriate facility for high-level intensive care. In general, the management of the sick neonate requires continuous monitoring of heart rate, respiratory rate and oxygen saturation. Temperature, blood pressure, blood glucose and observations are needed; blood examinations and chest X-ray will also be required (Russell et al, 2020). If necessary, respiratory support should ideally be delivered via high-flow nasal cannula or non-invasive ventilation. If full ventilatory support is required, closed-circuit ventilation with a HEPA filter and closed suctioning is essential to reduce aerosolisation of coronavirus particles (Edelson et al, 2020). Antibiotics should be prescribed only to babies with probable or confirmed bacterial infection; empirical use should be avoided unless indicated by the health of the baby (Russell et al, 2020).
Finally, for this section is a consideration of discharge home. Parents and family require education in effective home-isolation procedures and continued droplet precautions, and to seek immediate healthcare assistance if any signs of deterioration, such as fever, poor feeding, lethargy or drowsiness or decreased urine output are noted in the baby (Carvalho et al, 2020). Follow-up appointments are required for any positive SARS-CoV-2 newborns for up to 14 days after hospitalisation; these may be made by telephone or telemedicine preferably, or face-to-face if necessary (Carvalho et al, 2020). The midwifery team and/or child health nurse undertaking face-to-face, follow-up baby checks need to be aware of the SARS-CoV-2status of all members of the family to ensure essential personal protection.
The importance of human breast milk and breastfeeding
Human milk is the perfect food for newborns and there is also emerging but yet unsubstantiated evidence that human milk is protective against SARS-CoV-2 (Fox et al, 2020). Human milk contains substances that modulate the inflammatory response and these could be beneficial to the newborn during COVID-19. Human milk provides the balance between the protective inflammatory processes and the modulation of inflammation to protect the newborn against infection (Cacho and Lawrence, 2017). Anti-inflammatory and pro-inflammatory cytokines co-exist in human milk; however, the anti-inflammatory cytokines dampen the T Helper cells' 1 cytokine response, resulting in an inhibition in the release of pro-inflammatory cytokines (Field, 2005). Osteoprotegerin, a member of the tumour necrosis factor family also helps the T cells to dampen the inflammatory response. Lactoferrin inhibits the production of proinflammatory cytokines (Field, 2005), while epidermal growth factor also has anti-inflammatory properties.
Concerns were raised at the start of the pandemic as to whether SARS-CoV-2 could be transmitted to babies from breastmilk. However, at present, data are not sufficient to conclude vertical transmission of SARS-CoV-2 through breastfeeding. In babies, as the risk of SARS-CoV-2 infection is low and the infection is typically mild or asymptomatic, the consequences of not breastfeeding along with any potential separation mother from her baby requires attention. As SARS-CoV-2 in babies and children presents a lower threat to public health than other infections that breastfeeding is protective against, the benefits of breastfeeding are particularly important. Nurturing mother-baby interaction to promote health and development are imperative when health and other community services are disrupted or limited. Vital to remember though is that adherence to infection prevention and control measures is essential to prevent contact transmission between SARS-CoV-2-suspected or confirmed mothers and their babies.
As there has been much controversy and discussion around the separation of mothers and babies, skin-to-skin care and breastfeeding; the WHO guidelines are clear. Mothers and babies, with either absent, suspected or confirmed SARS-CoV-2, should be able to remain together both day and night. Skin-to-skin contact, including kangaroo mother care should be encouraged, especially immediately following birth and the initiation and establishment of breastfeeding is essential for optimal survival (WHO, 2020a). Mothers with confirmed, or suspected of being, SARS-CoV-2-positive should wear a face mask if one is available; however, if this is not possible, breast feeding should continue.
While the specific recommendations on breastfeeding are continually being updated and based on available evidence, the WHO recommendations on the initiation and continued breastfeeding of infants and young children also apply to mothers with suspected or confirmed SARS-CoV-2.
The impact of COVID-19 restrictions
The impact of social distancing must not be under-estimated. When the pandemic took hold, neonatal units across the globe began to implement revised visiting policies to restrict the presence of parents and extended family, to protect hospitalised neonates (de Rose et al, 2020; Green et al, 2020b). These policies were aimed at minimising potential sickness in healthcare professionals as well as protect the vulnerable neonates. The unfortunate consequence of such policies however, resulted in potentially long periods where parents were unable to see or touch their baby. Mask wearing became common place interfering with the usual means of essential non-verbal communication between parents and staff, and importantly, parents and their babies in the early days of life when attachment and bonding are taking place (Green et al, 2021).
Furthermore, the impact of early separation on attachment between parent and baby, and parental mental health has been well documented (Petty et al, 2018; Fowler et al, 2019) and practices, such as skin-to-skin contact and family integrated care, positively influence infant development and breastfeeding rates (O'Brien et al, 2018). The implementation of these more recent COVID-19 policies can be challenging for families as well as midwives and other health professionals. The concern is that in preventing beneficial strategies, such as participation in their baby's care and the nurturing of their parenting role, may increase parental stress, depression, and anxiety due to parent-infant separation as well as potential disruption to communications with healthcare professionals (Gallagher et al, 2018; Green et al, 2021).
Midwives, neonatal nurses and health professionals have quickly adapted to this challenge and engaged in a balancing act of providing optimum care to families and neonates while at the same time, ensuring the safety of their colleagues, their own families, and the wider public. Where separation is deemed necessary, technology such as apps and live video streams have been used to minimise isolation and improve family bonding (Khashu et al, 2020).
An interesting occurrence reported from Ireland (Philip et al, 2020) and Denmark (Hedermann et al, 2020) was an unexpected fall in preterm births following the first nationwide lockdown, as discussed by Green et al (2020b) with a 73% reduction in the number of premature babies born, when compared to the average for the same first four months of the year in the preceding two decades (Philip et al, 2020). Danish researchers found the birth rate of extremely premature infants decreased significantly (~90 % reduction) during the lockdown compared to the preceding five years (Hedermann et al, 2020). In Ireland, the reduction has been attributed to the potential effect of positive lifestyle influences during isolation and COVID-19 restrictions and the reduced exposure to ordinary stressors at work, such as commuting along with increased family support, better infection avoidance, improved sleep, nutrition and exercise, and reduced exposure to tobacco and illegal drugs (Philip et al, 2020).
The Danish research identified similar factors, suggesting risk factors for premature birth such as increased systemic maternal inflammation and other immunologically mediated processes may be negated by the increased focus on hygiene, physical distancing, and home confinement during the lockdown (Hedermann et al, 2020). Additionally, the decrease in air pollution caused by the lockdown restrictions may have also played a role in the observed reduction of premature birth, as air pollution, particularly the anthropogenic PM2.5 (fine particulate matter that can remain airborne for long periods and travel hundreds of miles), is associated with 18 % of premature births globally (Hedermann et al, 2020).
World Health Organization recommendations
Globally, and within countries, midwives are facing unique challenges related to the provision of midwifery care and the probable resultant long-term consequences for both mothers and newborns from this pandemic. Maternal and newborn health will not only be impacted through the direct effect of COVID-19 on the mother and/or baby but through the disruption to health systems and services (Robertson et al, 2020). The WHO (2020b; 2020c) recognises this and has provided recommendations to support the continuation of essential services wherever possible with maternal and newborn health as a priority. With predictive modelling suggesting that with only a 10% decline in maternal and newborn services, an estimated 28 000 maternal and 168 000 newborn deaths could result, this advice from the WHO is timely (Riley et al, 2020). This, when it is already known that there are approximately 300 000 maternal deaths, 2.5 million neonatal deaths and 2.6 million stillbirths each year, is concerning. This figure could be underestimated when considering disruption to family planning services resulting in more unplanned and unwanted pregnancies (WHO, 2020d; 2020e).
It is, therefore, important to have clear, contemporary recommendations and guidelines based on the best available evidence that are also easily understandable (WHO, 2020a; 2020b; 2020c; 2020d; 2020e; 2020f). The WHO's recommendations are in key areas of antenatal, labour and delivery. When antenatal care is disrupted, the recommendations include prioritising contact with mothers in their last trimester and those at high risk; booking visits to avoid overcrowding and where possible use digital platforms for antenatal screening. During labour and early postnatal period, recommendations include ensuring that caesarean sections are medically justified for women with suspected or confirmed SARS-CoV-2. Partners should be screened for SARS-CoV-2 and early skin-to-skin contact and the initiation of breastfeeding is essential (WHO, 2020e).
Conclusion
The cases of neonatal SARS-CoV-2 have been limited to date. Understandably, much of the knowledge emerging on SARS-CoV-2 infection in maternal and perinatal healthcare has focused on late pregnancy, delivery and the neonatal period. It is still unclear what the effects are of maternal exposure in early pregnancy and whether SARS-CoV-2 is indeed teratogenic (Semaan et al, 2020). As the number of confirmed cases of SARS-CoV-2 increases globally, more definitive evidence is required on the short- and long-term maternal, fetal and neonatal outcomes to ascertain the impact in the neonatal population (Kimberlin and Stagno, 2020) and beyond.
The world is facing a rapidly developing clinical situation. The global maternal and neonatal community needs to address the impact and develop policies to protect neonates, parents, and staff. Concern for the vulnerable, high-risk neonatal population goes beyond vertical transmission. It is acknowledged that there is a risk to mothers and neonates who may acquire SARS-CoV-2 through close contact with those infected or carrying the virus (Wang et al, 2020).
Understandably, the research related to neonatal SARS-CoV-2 infection is limited and in very early stages and unfortunately much of the literature is vague and contradictory. For example, there is still no clear consensus on vertical transmission of the virus. Also, some case studies suggest SARS-CoV-2 in the neonate is less severe but this requires much more robust research. Furthermore, future research needs to focus on maternal infection in early pregnancy and whether the virus is teratogenic. The most recent and promising research related to dexamethasone in reducing mortality, needs to be extended to antenatal dexamethasone use in preterm labour and potential positive impacts on neonatal SARS-CoV-2 infection.
Finally, the COVID-19 pandemic has presented midwives with challenges when caring for mothers and babies. This review and the preceding paper (part 1) have presented what is currently known about SARS-CoV-2 and maternal and neonatal health. Further information and research as they are generated will add to a complete picture of the health outcomes.
Key points
- Naivete of the neonatal immune system may afford protection against the inflammatory response of COVID-19 in adults
- Changes in practice and policies in response to the COVID-19 pandemic has had an impact on the care of the baby
- Newborn health may be impacted through the direct effect of COVID-19 and disruption to health services
- Research and midwifery knowledge related to neonatal COVID-19 infection is limited but rapidly emerging
- COVID-19 must be taken seriously because of potential disease transmission and the ramifications of social distancing policies
CPD reflective questions
- What are the key differences between the neonatal and adult immune systems that may afford protection against the inflammatory response of COVID-19 in babies?
- What changes in practice and policies in response to the COVID-19 pandemic have had an impact on the care of the baby?
- How may newborn health be impacted through the direct effect of COVID-19 and disruption to health services?
- What are the key areas of research and midwifery knowledge related to neonatal COVID-19 infection that are emerging?
- What are the ramifications of social distancing policies on midwifery practice in caring for newborn babies?