Care of a Neonate Born to a Mother who is Confirmed to have Ebola, is a Person under Investigation, or has been Exposed to Ebola

Interim Guidance for U.S. Hospitals on the Care of a Neonate Born to a Mother who is Confirmed to have Ebola, is a Person under Investigation (PUI), or has been Exposed to Ebola

Who this is for: Healthcare professionals working with neonates in labor and delivery, neonatal intensive care units, newborn nurseries, and other settings in U.S. hospitals.

What this is for: Guidance on how to care for neonates born to mothers exposed to Ebola virus, PUIs, or with confirmed Ebola.

How to use this: This guidance is intended to help U.S. hospitals develop plans for treating neonates born to PUIs or to mothers with confirmed Ebola. Note: Ideally, these mothers and neonates will be cared for in Ebola assessment hospitals (if the mother is a PUI) or Ebola treatment centers (if the mother is confirmed to have Ebola.)¹

What is known about neonates born to mothers with Ebola?

While data are limited, reports from Ebola outbreaks indicate that spontaneous fetal loss is high among pregnant women with Ebola.^2-4 Neonates born to women with Ebola are often premature,⁵ and typically do not survive for more than a few weeks.^2,6,7 It is not clear whether these deaths are due to transmission of Ebola virus from mother to the neonate or to other factors that contribute to high infant mortality rates in Ebola-affected countries;⁷ however, recent data have suggested there is in utero transmission of Ebola virus to the fetus.⁴ Further, there are limited data on clinical signs at presentation of Ebola in neonates. In a 1976 outbreak, among 11 neonates born to mothers with Ebola, seven had fever with few other signs.⁷ There is no experience with neonates born to women with Ebola in settings with a highly developed healthcare system.

The following guidance is based on the current, yet limited, knowledge and best practices for infection control.  As more information is learned about neonates born to mothers with Ebola, this guidance may change. Additionally, guidance is available from CDC on caring for pregnant women with Ebola in U.S. hospitals.⁸

Care of neonates born to mothers with confirmed Ebola

Because it is not known if, or when, all neonates born to mothers with Ebola acquire Ebola virus infection perinatally, neonates delivered of mothers with confirmed Ebola should be considered a PUI.  Local public health officials and CDC should be alerted. Neonates should be immediately separated from their mothers and cared for in an isolation unit for 21 days. Healthcare workers caring for these neonates should follow recommendations for use of personal protective equipment (PPE) when caring for patients with Ebola.⁹ Treatment decisions should be made by the clinical team caring for the patient. However, infection control considerations may help to inform providers’ decisions and should influence hospitals’ planning processes. If resuscitation is indicated, it should occur with adherence to isolation precautions, environmental hygiene, and waste management, as well as worker safety practices that include the use of PPE, and in accordance with the principles of the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program.^9,10 Decisions to discharge the neonate after 21 days of monitoring with no signs of infection and a negative result of Ebola virus testing by RT-PCR on a blood specimen should be made in conjunction with local public health authorities.

Care during isolation: To date, there have been no reports of healthy neonates delivered of pregnant women with confirmed Ebola. However, in the circumstance that a neonate is healthy and stable after delivery of a pregnant woman with confirmed Ebola, routine newborn care should be provided and non-invasive screening tests should be conducted.¹¹ (See Table 1) Appropriate PPE should be worn at all times⁹. Decisions to delay invasive screening tests and immunizations should consider the diagnosis of Ebola in the neonate, maternal conditions (such as Hepatitis B), and family history. Circumcision should be delayed until the 21-day isolation period has concluded and/or a negative result of Ebola virus testing by RT-PCR on a blood specimen has been documented to prevent the exposure of healthcare workers to Ebola virus. Decisions on when circumcision can safely be performed should be made in conjunction with local public health authorities. A careful history should be sought to ensure that the mother was screened for other causes of tropical febrile illnesses that could contribute to increased morbidity in the neonate, especially malaria. If the neonate becomes febrile during hospitalization, local causes of fever, including hospital-acquired bacterial infections and viral illnesses other than Ebola, should also be sought.

Breastfeeding Recommendations:In a few situations where breast milk was tested after recovery from EVD, Ebola virus genetic material was identified in the breast milk of two different lactating women from 6 to 26 days after disease onset.^{13, 14} Because Ebola virus has been shown to be present in breast milk, neonates born to pregnant women with confirmed Ebola virus infection should not breastfeed. There is not enough evidence to provide guidance on when it is safe to resume breastfeeding after the mother recovers from EVD. Where available, testing of breastmilk for the presence of Ebola virus genetic material can help to guide decisions about when breastfeeding can be safely resumed.

Donor breast milk or Ready to Use Infant Formula (RUIF), if available, may be an acceptable substitute.

Safe Handling of Breast Milk in Healthcare Settings: Standard precautions for prevention of transmission of bloodborne pathogens do not apply to human breast milk in most circumstances.¹⁵ However, there are no data about the risks from exposure to breast milk containing Ebola virus in healthcare settings. Thus, when a mother has confirmed Ebola virus infection, PPE guidance should be followed for anyone handling her breast milk.^9,16 The expressed milk of a mother with confirmed Ebola virus infection is considered Category A infectious waste and must be disposed of in accordance with CDC guidance on waste management.¹⁷

Care of neonates born to PUIs

Neonates born to mothers under investigation for Ebola should be treated as a PUI until the Ebola virus status of the mother is determined. Neonates should be immediately separated from their mothers, placed into isolation for 21 days, monitored for Ebola virus infection, and cared for with appropriate PPE.⁹ If the mother is confirmed to have Ebola, healthcare workers should follow the guidance above on care of a neonate born to a mother with confirmed Ebola. If it is determined that the mother does not have Ebola, the neonate may be removed from isolation and cared for using standard hospital protocol. However, if the mother later develops signs and symptoms consistent with Ebola during her 21 days of monitoring, the neonate should be separated immediately, placed into an isolation unit and cared for with appropriate PPE until Ebola virus infection in the neonate is ruled out .⁹ If the mother tests positive for Ebola virus, the 21-day monitoring period would be reset for the neonate to the date of last contact with the mother. Decisions to discharge the neonate after 21 days of monitoring with no signs of infection and a negative result of Ebola virus testing by RT-PCR on a blood specimen should be made in conjunction with local public health authorities.

Care during isolation: Neonates born to mothers under investigation for Ebola should be cared for using the same guidelines used for neonates born to mothers with confirmed Ebola, until the Ebola virus status of the mother is determined.

Breastfeeding Recommendations: A mother who is under investigation for Ebola should not breastfeed until her Ebola virus infection status is resolved. Donor breast milk, if available, may be an acceptable substitute. To establish and maintain breast milk production, she may express her breast milk. If pumping, she must use a dedicated breast pump that remains in the patient’s room. The breast pump must not be used for any other patient. Upon determination that the mother does not have Ebola, she may begin breastfeeding. Upon confirmation of Ebola, the guidance for a mother with confirmed Ebola should be followed as described above.

Safe Handling of Breast Milk: When a mother is under investigation for Ebola, PPE guidance should be followed for anyone handling her breast milk.^9,16 The expressed milk of a mother classified as PUI is considered Category A infectious waste and must be disposed of in accordance with CDC guidance on waste management.¹⁷

Care of neonates born to asymptomatic mothers with potential exposure to Ebola virus

Neonates born to asymptomatic mothers who had potential exposure to Ebola virus should be placed in the same risk category as their mothers and followed using the monitoring protocol outlined in the Interim US Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure.¹⁸ Neonates can remain in the same room with their mothers, unless the mother or neonate becomes symptomatic, at which time they should be separated.  Neonates should be monitored with twice daily rectal temperatures and assessed for signs of infection and other changes in behavior (e.g., not feeding well, excessive sleepiness, uncontrollable crying) as signs of many neonatal infections are often vague. Depending on the risk category, this monitoring may begin in the hospital and continue at home after discharge. Decisions to discharge the neonate should be made in conjunction with local public health authorities. Monitoring should continue until 21 days have elapsed since the mother’s last known exposure to Ebola virus. 

Routine care: For neonates who appear healthy and stable after delivery, routine newborn care should be provided and non-invasive screening tests should be conducted.¹¹ Invasive screening tests and immunizations should be conducted as long as the mother and neonate remain asymptomatic. Circumcision should be delayed until the 21 days of monitoring have ended. (See Table 1)

Breastfeeding Recommendations: A lactating mother who has suspected EVD should not breastfeed until her Ebola virus infection has been excluded. Donor breast milk or Ready to Use Infant Formula (RUIF), if available, may be an acceptable substitute. To establish and maintain breast milk production during this time, she may express her breast milk. If pumping, she must use a dedicated breast pump that remains in the patient’s room. The breast pump must not be used for any other patient. Milk positivity should be checked at regular interval. Upon confirmation of Ebola virus infection, the guidance for a mother with confirmed Ebola virus infection should be followed as described above.

Safe Handling of Breast Milk in Healthcare Settings: When a mother is under investigation for Ebola virus disease, PPE guidance should be followed for anyone handling her breast milk.^9,16 The expressed milk of a mother classified as PUI is considered Category A infectious waste and must be disposed of in accordance with CDC guidance on waste management.¹⁷

Involvement of Family Members

Neonates born to asymptomatic mothers with potential exposure to Ebola virus should be allowed visitors according to standard hospital protocol. In accordance with CDC guidance on “Infection Prevention and Control  Recommendations for Hospitalized Patients Under Investigation (PUIs) for Ebola Virus Disease in U.S. Hospitals,” visitors should not be allowed for neonates born to mothers with confirmed Ebola until the neonate is beyond 21-days of age and determined to be non-infected with Ebola virus.¹⁶  Visitors should not be allowed for neonates born to mothers under investigation for Ebola until the mother’s Ebola virus infection status is resolved. Exceptions may be considered on a case-by-case basis (e.g., the father of the baby is dying), after careful consideration of the risks and benefits and in consultation with public health authorities. Consideration should be given to the use of visual observation through a window or through the use of videoconference technology, instead of in-person visitation.  If an exception is made for in-person visitation, PPE guidance should be followed.⁹

There is no known risk of transmission of Ebola virus via breastfeeding for infants born to women who became pregnant after recovering from EVD.¹⁹

• Breastfeeding is safe and should be recommended for women who, after recovering from EVD, become pregnant and give birth.

 

Table 1. Neonatal care during isolation and monitoring for neonates born of mothers with confirmed Ebola, under investigation for Ebola, and with potential exposure to Ebola virus.

	Neonates born to mothers with confirmed Ebola and neonates born to mothers under investigation for Ebola	Neonates born to asymptomatic mothers with potential exposure to Ebola virus
Routine Newborn Care Includes but is not limited to  clinical examination, assessment of gestational age, measurement of weight, length, and head circumference, skin care, bathing, eye prophylaxis and parenteral vitamin K.11	Should be provided.	Should be provided.
Non-invasive Screening Tests  Includes but not limited to critical congenital heart disease screening, hearing screening.	Should be conducted.	Should be conducted.
Invasive Screening Tests and Immunizations  Includes but not limited to newborn heel stick screening.	Ebola diagnosis in the neonate, maternal conditions (e.g. Hepatitis B), and family history, should guide the decision to perform invasive screening tests and/or immunizations. In the absence of a negative result of Ebola virus testing by RT-PCR on a blood specimen in the neonate, newborn heel stick screening may need to be deferred until the 21 day isolation period has concluded and/or a negative result of Ebola virus testing by RT-PCR on a blood specimen has been documented to prevent the exposure of healthcare workers to Ebola virus and avoid contamination of lab equipment. Decisions on when invasive newborn screening and immunization can safely be performed should be made in conjunction with local public health authorities.	Should be conducted as long as the mother and neonate remain asymptomatic.
Circumcision	Should be delayed until the 21-day isolation period has concluded and/or a negative result of Ebola virus testing by RT-PCR on a blood specimen has been documented to prevent the exposure of healthcare workers to Ebola virus. Decisions on when circumcision can safely be performed should be made in conjunction with local public health authorities.	Should be delayed until the 21 days of monitoring have ended. Decisions on when circumcision can safely be performed should be made in conjunction with local public health authorities.

References

1. Centers for Disease Control and Prevention. Interim Guidance for U.S. Hospital Preparedness for Patients Under Investigation (PUIs) or with Confirmed Ebola Virus Disease (EVD): A Framework for a Tiered Approach. https://www.cdc.gov/vhf/ebola/healthcare-us/preparing/hospitals.html. Published 2015. Accessed March 10, 2015.
2. Mupapa K, Mukundu W, Bwaka MA, Kipasa M, De Roo A, Kuvula K, et al. Ebola hemorrhagic fever and pregnancy. The Journal of infectious diseases. 1999;179, Suppl 1:S11-12.
3. Jamieson DJ, Uyeki TM, Callaghan WM, Meaney-Delman D, Rasmussen SA. What obstetrician-gynecologists should know about ebola: a perspective from the centers for disease control and prevention. Obstetrics and gynecology. 2014;124(5):1005-1010.
4. Baggi FM, Taybi A, Kurth A, Van Herp M, Di Caro A, Wölfel R, Günther S, Decroo T, Declerck H, Jonckheere S. Management of pregnant women infected with Ebola virus in a treatment centre in Guinea, June 2014. Euro Surveill. 2014;19(49).
5. Wamala JF, Lukwago L, Malimbo M, Nguku P, Yoti Z, Musenero M, et al. Ebola hemorrhagic fever associated with novel virus strain, Uganda, 2007-2008. Emerging infectious diseases. 2010;16(7):1087-1092.
6. Francesconi P, Yoti Z, Declich S, Onek PA, Fabiani M, Olango J, et al. Ebola hemorrhagic fever transmission and risk factors of contacts, Uganda. Emerging infectious diseases. 2003;9(11):1430-1437.
7. World Health Organization. Ebola haemorrhagic fever in Zaire, 1976. Bulletin of the World Health Organization. 1978;56(2):271-293.
8. Centers for Disease Control and Prevention. Guidance for Screening and Caring for Pregnant Women with Ebola Virus Disease for Healthcare Providers in U.S. Hospitals. https://www.cdc.gov/vhf/ebola/healthcare-us/hospitals/pregnant-women.html. Published 2014. Accessed December 16, 2014.
9. Centers for Disease Control and Prevention. Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing). https://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html. Published 2014. Accessed December 17, 2014.
10. American Academy of Pediatrics and American Heart Association. NRP Neonatal Resuscitation Textbook 6th Edition (English version)2011.
11. AAP Committe on Fetus and Newborn and ACOG Committee on Obstetric Practice. Care of the Newborn.  Guidelines for Perinatal Care, 7th Edition. Elk Grove Village2012.
12. Centers for Disease Control and Prevention. Recommendations for Breastfeeding/Infant Feeding in the Conxtext of Ebola. https://www.cdc.gov/vhf/ebola/hcp/recommendations-breastfeeding-infant-feeding-ebola.html. Published 2014. Accessed Nov 7, 2014.
13. Bausch DG, Towner JS, Dowell SF, Kaducu F, Lukwiya M, Sanchez A, et al. Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. The Journal of infectious diseases. 2007;196 Suppl 2:S142-147.
14. Nordenstedt H, Bah IE, de la Vega M-A, et al. Ebola Virus in Breast Milk in an Ebola Virus–Positive Mother with Twin Babies, Guinea, 2015. Emerging Infectious Diseases. 2016;22(4):759.
15. Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. MMWR 1988;37(24):377-388. https://www.cdc.gov/mmwr/preview/mmwrhtml/00000039.htm Accessed February 6, 2015.
16. Centers for Disease Control and Prevention. Infection Prevention and Control Recommendations for Hospitalized Patients Under Investigation for Ebola Virus Disease in U.S. Hospitals. https://www.cdc.gov/vhf/ebola/healthcare-us/hospitals/infection-control.html Published 2014. Accessed February 6, 2015.
17. Centers for Disease Control and Prevention. Ebola-Associated Waste Management. https://www.cdc.gov/vhf/ebola/hcp/medical-waste-management.html. Published 2014. Accessed December 17, 2014.
18. Centers for Disease Control and Prevention. Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure. https://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html#table-monitoring-movement. Published 2014.
19. Kamali A, Jamieson DJ, Kpaduwa J, et al. Pregnancy, Labor, and Delivery after Ebola Virus Disease and Implications for Infection Control in Obstetric Services, United States. Emerg Infect Dis. 2016;22(7). [Epub ahead of print.] DOI: 10.3201/eid2207.160269. http://dx.doi.org/10.3201/eid2207.160269. Accessed June 8, 2016.