The COVID-19 pandemic has waged a toll across the world, not seen in over a century. Although there are still some countries who are in the midst of a 2nd or even 3rd wave, with the recent expansion of vaccine eligibility to adolescents as young as 12 years of age, it appears that the United States may be able to put the worst of the virus behind her. Hospitalizations and deaths continue to drop on a near-daily basis.
However, there was a great deal to learn from this pandemic that can be used in the future in how we care for patients and families. This holds true in neonatology, as well. At the UVA NICU, two team members utilized the pandemic to shed light on the impact of the pandemic on family visitation in the NICU. Like most NICUs, the NICU at UVA implemented visitation restrictions once the pandemic hit. In a recent Journal of Perinatology perspective, Drs Peter Murray, Assistant Professor of Pediatrics and a member of UVA Health’s Ethics committee, and Jonathan Swanson, Associate Professor of Pediatrics and Medical Director of the NICU, discussed how the COVID-19 pandemic impacted family visitation, ways in which NICUs could still support families during the restrictions, and the ethical issues involved in restricting parental access to their sick or premature infant. “The COVID-19 pandemic forced healthcare systems and providers at the bedside of patients to make unpopular choices in defense of public health. The limitation of visitation represented one such unpopular choice. Some healthcare systems went so far as to completely ban visitation in all forms, even if the patient is a neonate. Such draconian measures would be warranted if there were no reliable ways to impact a communicable disease’s transmission rate. For SARS-CoV-2, reliable prevention measures include masking and gloving and quarantine when ill or exposed to the infectious agent. With such measures possible in the neonatal intensive care unit (NICU), the absolute prevention of parental visitation is an egregious violation of a parent’s right to assemble at their baby’s bedside freely.” said Dr. Murray.
When the pandemic started, we did not know if vertical transmission would occur frequently or not, and if newborns with their developing immune system would be highly susceptible to infection, morbidity, and mortality from COVID-19. The answers to challenging questions of whether it was safe or not for mothers and their newborns to be together and breastfeed were not known. We had no data whether breast milk would be protective with important antibodies against SARS-CoV-2 or a source of transmission. Separating mother-baby dyads ran counter to all the benefits of rooming in practices, but maybe it would prevent transmission and the harmful sequelae we were learning about COVID-19. Initially, about one-half of birth centers were separating mothers and babies, with the other half keeping them together with guidelines for maternal masking and hand hygiene with care, contact, and breastfeeding.
Within a few months, data from key studies and the National Perinatal COVID-19 Registry emerged, supporting the idea that infants should not be separated from their SARS-CoV-2 positive mothers if they were able to care for their newborn. In an editorial in JAMA Pediatrics, “Making Room for Rooming in” was discussed. Dr. David Kaufman, Professor of Pediatrics and Assistant Medical Director of the NICU, wrote with Dr. Karen Puopolo from the Children’s Hospital of Philadelphia, that based on the low rate (<2%) of both vertical and horizontal perinatal transmission of the SARS-CoV-2 virus, clinicians can feel reassured that infants can safely stay “where they belong” with their mothers, as well as breastfeed.
Dr. Kaufman, along with Neonatal-Perinatal Medicine Fellow Dr. Jaclyn Wiggins, have also collaborated with physicians from the University of Pennsylvania and Duke University in evaluating the impact that masking and other COVID-19 infection prevention measures that were instituted have had on late-onset infections in the NICU. Recently presented in the Top 10 Pediatric Infectious Disease Society Abstracts at the Pediatric Academic Societies (PAS) 2021 Annual Meeting, the team has preliminarily found that after implementation of these additional infection prevention measures, there was a 41% reduction in blood stream infections across the centers and potentially a decrease in viral infections as well. The team is currently evaluating the data from 12 centers across the United States and Canada.
The Neonatal Sepsis Club, also at PAS 2021, was chaired by Dr. Kaufman and entitled, “An Ounce of Prevention….” and dove into the area of maternal vaccination against SARS-CoV-2. The history of vaccination of pregnant women is complicated by both a complex biology and social perception of vulnerability and safety. The success of the COVID-19 vaccine demonstrating benefit and safety to both mothers and their newborns may help move maternal vaccination forward against other diseases, as well.
For more information, please see:
Wiggins JB, Bultmann CR, Garber SJ, Conaway M, Mukhopadhyay S, Flannery DD, Dhudasia MB, Weitkamp JH, Cantey JB, Schelonka R, Ziegler K, Chang E, Gaulton J, Tuttle D, Favara M, Khan S, Berenz A, Wohrley J, Weimer K, Gilfillan M, Carey A, Vyas D, Sanchez PJ, Kaufman DA. Potential Benefit of Masking and other COVID-19 Infection Prevention Measures on Late-Onset Infections in the NICU. PAS 2021 Publication #:EP-511-4-PL-L.4.
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