Table 4 Neonatal care policies (after Chandrasekaran et al) [77]

Transplacental transmission

• Although the presence of the angiotensin-converting enzyme 2 receptor used by SARS-CoV-2 in the placenta [21, 98], makes transplacental transmission plausible, to date, this has only been confirmed in a minority of cases [99,100,101,102].

Delayed cord clamping (DCC)

• Continue in accordance with unit policies. Benefits of DCC include increased haemoglobin and iron stores in term infants, and improved transitional circulation, better establishment of red blood cell volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular haemorrhage in preterm infants [103].

• [In COVID-19 positive or suspected mothers, some groups recommend immediate cord clamping [13, 15, 21, 36, 39, 42, 78, 82], while others encourage DCC [4, 77, 88]. Shared decision-making on risks and benefits is recommended]

Neonatal resuscitation

• Drying, tactile stimulation, and assessment of heart rate are non-aerosol-generating, while suction or endotracheal intubation or medication instillation, are considered to be AGMPs, and therefore require donning of PPE by the resuscitation team [21].

• [For neonates born to COVID-19 positive or suspected mothers, resuscitation should be carried out in a separate room, and, if not feasible, at a distance of 6 m apart with a physical barrier between mother and baby, preferably in an isolette with a hood [77].]

• [It is also recommended that neonates born to persons with active COVID-19 infections are washed as soon as possible after birth in order to reduce transmission risk [21, 77].]

• [Although it has been suggested that designated resuscitation teams attend all COVID-19 positive or suspected births, in order to minimize exposure to care providers and uninfected persons [77], this may not be necessary in areas of low prevalence and neonatologists could only attend births where the neonate is likely to require resuscitation or early neonatal care.]

Skin-to-skin

• Continue in non-infected individuals, since this practice has numerous benefits including decreased postpartum maternal anxiety, decreased depression in the first year postpartum, increased uterine tone with decreased bleeding, and improved weight gain and sleep quality in the newborn [88].

• [Although skin-to-skin contact between a COVID-19 positive or suspected parent and a neonate has been discouraged by many [13, 15, 21, 34, 35, 39, 42, 76, 81, 82, 104], due to the risk of postnatal transmission, this may still be possible following shared decision-making in asymptomatic individuals, with mask-wearing and appropriate hand and breast hygiene.]

Breastfeeding

• Continue to offer in non-infected persons.

• [For those with suspected or confirmed COVID-19, the risk of transmission of SARS-CoV-2 to infants is more likely to be via respiratory droplets while feeding as opposed to transmission via breastmilk [105]. Options include: (1) no breastfeeding and no feeding of expressed breastmilk [39, 81], (2) no breastfeeding but permitting the feeding of expressed breastmilk to infant [18, 82, 106], (3) direct breastfeeding [53, 57, 105, 107]. Some groups specify that a mother with asymptomatic or mild disease may breastfeed, but if severely or critically ill only expressed breastmilk should be used [21, 34]. Given that these recommendations are based on limited evidence, decisions should be individualized, and consider all pros and cons. While not breastfeeding, neonates should be at least 6 ft away from infected mothers, and mothers should be masked at all times. Those not comfortable with the risks of breastfeeding should be encouraged to express breastmilk.]

Separation or co-location of mother and baby

• [Many groups recommend separation of mother and baby in the case of confirmed or suspected COVID-19 [15, 18, 39, 50, 76, 81, 108, 109], while others permit rooming-in for infants with precautionary measures in place [34, 53, 57, 88]. Shared decision-making is encouraged, if the mother is not too unwell to care for the baby.]

Neonatal testing

• There is considerable variation in testing of babies born to unaffected mothers, and decisions should be based on local-prevalence, availability of testing and local policies. Some groups tested all babies admitted to the NICU [110], while others recommended against it as this often resulted in false negative results [53].

• [Testing of neonates born to mothers with confirmed or suspected COVID-19, regardless of maternal symptoms, at approximately 24 h of age is widely practiced [21, 57, 81, 104, 111]. If initial test results are negative, or not available, repeat testing is recommended at 48 h of age [21, 104]. Placental and cord blood samples may be collected and tested by swab and histopathology in order to better understand transplacental transmission.]

Visitor policies

• Decisions should be individualized based on local prevalence, condition of the neonate and resource-availability. Modifications to visitor policies included limiting visitors to one parent at a time [15, 57, 110], with some groups specifying mothers only [57], or to none at all [83, 110].

• If screen-negative parents are permitted to visit, consider restricting movement in and out of the NICU’