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DOI:
REVIEWARTICLE
Obstetrics
COVID-­19guidelinesforpregnantwomenandnewmothers:A
systematicevidencereview
MadelineA. DiLorenzo1 |SarahK. O’Connor2 |Caroline Ezekwesili3 |
Spoorthi Sampath4 |Molly Zhao4 |Christina Yarrington2 |Cassandra Pierre1
1DepartmentofInternalMedicine,Boston
MedicalCenter,Boston,MA,USAAbstract
2DepartmentofObstetricsandBackground:NearlyayearafterCOVID-­19wasinitiallydetected,guidanceforpreg-
Gynecology,BostonMedicalCenter,
Boston,MA,USAnantandnewmothersremainsvaried.
3BostonUniversitySchoolofPublicObjective:Thegoalofthissystematicreviewistosummarizerecommendationsfor
Health,Boston,MA,USAthreeareasofmaternalandfetalcare—­breastfeeding,post-partum­socialdistancing,
4BostonUniversitySchoolofMedicine,
anddecontamination.
Boston,MA,USA
Searchstrategy:WesearchedPubMed,EmbaseandWebofSciencespanningfrom
Correspondence
inceptiontoNovember9,2020.
,BostonMedical
Center,1BostonMedicalCenterPlace,Selectioncriteria:ArticleswereincludediftheyfocusedonCOVID-positive­moth-
Boston,MA,02118,USA.
ers,commentedonatleastoneofthethreeareasofinterest,andwerepublishedin
Email:madeline.******@
English.
Datacollectionandanalysis:Ourcombineddatabasesearchyielded385articles.
Afterremovingduplicatesandarticlesthatdidnotcoverthecorrectpopulationsor
subjectmatter,atotalof74articlesremainedinouranalysis.
Mainresults:Mostarticlesrecommendeddirectbreastfeedingwithenhancedpre-
-­partumsocialdistancingvaried,
althougharticlespublishedmorerecentlyoftenrecommendedkeepingthemother
emphasizedmaskwearing,goodhandhygiene,andpropercleaningofsurfaces.
Conclusion:Ingeneral,therewasafocusonshareddecisionmakingwhenapproach-
ingtopicssuchasbreastfeedingandpost-­
decontaminationwerefairlyuniform.
KEYWORDS
breastfeeding,COVID-­19,post-­partumcare,pregnancy,skin-­to-­skincontact,SSC
1 | INTRODUCTIONpandemicbytheWorldHealthOrganization(WHO).2Thepandemic
hassincespreadacrosstheglobe,leadingtoover105millioncases
ThefirstcaseofCOVID-­19wasdetectedinWuhan,China,
November17,,Now,nearlyayearafterthefirstcaseofCOVID-­19,there
andonMarch11,2020,theCOVID-­,guidelines
’Connorcontributedequallytothismanuscript
andco-­firstauthors.
©2021InternationalFederationofGynecologyandObstetrics
| ;00:1–10.
2 | DILORENZOetal.
fornewmothers,bothwithandwithoutCOVID-­19,(forbreastfeeding);recommendations
UncertaintyinbestpracticescarriestangibleramificationsforregardingSSC,roominginofthemotherandnewbornwhileinthe
,earlyinthehospital,guidelinesonvisitors,andguidelinesondischargeplanning
pandemic,therewasconcernthataCOVID-­19positivemother(forpost-­partumsocialdistancing);andprecautionsforproviders,
couldtransmitthevirustoherchildthroughverticaltransmis-wastedisposal,equipmentmanagement,patienttransport,aerosol-
sionmechanisms(suchasbreastfeeding),althoughitisnowun-izingprocedures,decontaminationofworksurfaces,andprecau-
derstoodthatCOVID-­19isspreadprimarilythroughhorizontaltionsformothersandinfants(fordecontamination).
,5Incomparison,thebenefitsofFinally,thequalityofguidelineswasassessedusingthe“Appraisal
breastfeeding—­particularlyitsabilitytoprotectchildrenagainstofGuidelinesforResearchandEvaluationII”(AGREE-­II)
infectiousdiseasesthroughthedirecttransferofantibodies—­arefinalresultswerereviewedbythecompletelistofreviewauthors
.
Mothersalsoneedguidanceonhowtousepersonalprotec-
tiveequipment(PPE)andsocialdistancingtoprotectthemselves
andtheirchildrenfromCOVID-­19intheimmediatepost-­partum3 | RESULTS
,
questionshavebeenraisedregardinghowtobestbroachskin-­OurcombineddatabasesearchofPubMed,Embase,andWebof
to-­skincontact(SSC),,wefoundsix
forthosemotherswithoutconfirmedCOVID-­19,-­twoduplicate
,anadditional
post-­partumperiod,toensurethatthey,theirchildren,andother217articleswereexcludedastheydidnotcoverthecorrect
-­textassessmentofthe
Theobjectiveofthissystematicevidencereviewistoevaluateremaining142articles,68additionalarticleswereexcludedas
allavailablerecommendationsregardingbreastfeeding,decontam-theydidnotmakerecommendationsonanyareaofourfocus.
ination,andpost-­partumsocialdistancingfornewmothersduringThisresultedinafinallistof74articlesincludedinouranalysis
theeraofCOVID-­(a)provideasummaryofwhat(Figure 1).
hasbeenlearnedsincethefirstcaseofCOVID-­19wasidentifiedand
(b)toprovidesuccinctrecommendationstosupportcliniciansand
| Breastfeeding
Atotalof73ofthefinal74articlesdiscussedguidelinesforbreast-
2 | MATERIALSANDMETHODSfeedingduringtheCOVID-­19pandemicandwerethereforeused
inthefinalreview(Table 1).Thearticlesincludedarangeofpub-
WefollowedthePreferredReportingItemsforSystematicReviewslicationtypesspanningfromsystematicevidencereviewsornarra-
andMeta-­Analyses(PRISMA)guidelinesinourapproachtostudytivereviewswithsuggestedguidelines,tosingle-­sitecase-­reports.
,EmbaseAdditionally,therewasarangeofarticleauthorshipspanningfrom
andWebofSciencefrominceptiontoNovember09,
termsincludedMedicalSubjectHeadingsandfree-­texttermsFederationofGynecologyandObstetrics(FIGO)tospecificcoun-
relatedtoCOVID-­19andmothers,newbornbabies(Supportingtries’healthguidelinestopracticerecommendationsfromindividual
Information).Anarticlemetinclusioncriteriaifitsprimarysubjectclinicians.
wasCOVID-­positivemothersandifitmaderecommendationsonTheprimaryconcernforbreastfeedingbyCOVID-­positiveor
atleastoneofthefollowingthreeareasofmanagementinthesuspectmothersisviraltransmissiontothenewbornviabreast
postpartumperiod:breastfeeding,mother-­infantsocialdistanc-,manyagreedthattransmissionvia
ing,,articleshadtobepub-breastmilkisunlikelywhileasmallerproportionfeltevidencewas
.,whichwasoneofthefirstpublications
basedontheirabstract,thefulltextwasreviewedforcompletetodirectlyassessforpossibleverticaltransmissionofCOVID-­
(including
Oncethefinallistofarticleswasselected,allinformationrelatedbreastmilk,amnioticfluid,cordbloodandneonatalthroatswabs)
torecommendedpracticesand/
summarizedbythreeauthors(CE,SS,MZ)intoanExcel(Microsoft,ofbreastmilkweretestedandnegativeforevidenceofthevirus.
Redmond,WA,USA),verticaltransmissionthrough
thenreviewedandverifiedbythetwoco-­firstauthors(MD,SO).breastmilkdoesappearhighlyunlikelyassuggestedbytheUnited
ThevariablesofinterestwerelikelihoodofverticaltransmissionandStatesCentersforDiseaseControl(CDC).9
DILORENZOetal. | 3
FIGURE1 PreferredReportingItemsforSystematicReviewsandMeta-­Analyses(PRISMA)flowdiagram
| Post-­partumsocialdistancing
recommendationsforbreastfeedingbasedoninterpretationofthe
,includingthosebytheRoyalFromtheoriginaldatabasesearches,weidentified53articlesthat
CollegeofObstetriciansandGynecologists(RCOG),FIGO,andthediscussedsocialdistancingguidelinesforpost-­partumduringthe
WHO,supporteddirectbreastfeedingformotherswithsuspectedorCOVID-­19pandemic,allofwhichwereincludedinthefinalreview
confirmedCOVID-­19infection,withenhancedprecautionsformoth-(Table 2).Thearticlescitedincludesystematicevidencereviews,
–12­Enhancedprecautionfeaturesincludednarrativereviewswithsuggestedguidelines,andsingle-­sitecase-­
maskusage,stricthandhygiene,breastcleaning,breastmilkexpres-
sionviaadedicatedpumpwiththoroughpumpcleaning,andfeedingorganizationstospecificcountrieshealthguidelinestopracticerec-
.
thatsupporteddirectbreastfeedingindicatedthatexpressedbreastTherecommendationsregardingtheseparationofmotherand
milkcouldbeusedasanalternativeformotherswithmoreseverechildincasesofsuspectedorconfirmedCOVID-­19infectionvar-
,fewerorganizationsandauthorgroupsrec--
ommendedstrictmother-­childseparationanddedicateduseofalter-tineseparationofthemotherandnewbornimmediatelyafterbirth
,multipleregardlessofeitherthemotherorthechild'
groups,includingtheCDC,tookanuancedapproachtorecommen-specifiedthatseparationshouldoccuronlyifeitherthemotheror
dationsthatwererootedinshareddecisionmakingandsituationalchildwassymptomaticorhadsymptomaticcontacts,oriftheinfant
considerationstocreateafeedingplanthatworksbestforboththewashigh-­riskbecausetheywerepre-­termorhadrequiredcarein
,,69Forthoserecommendingsep-
werepresentedalongsideaneutralpresentationofdirectversusex-aration,thelengthofisolationtimevaried,withthelongestbeing
 
4 | DILORENZOetal.
TABLE1 Summaryofbreastfeedingrecommendations
TopicPreventionmeasuresStudies(referencenumber)
VerticaltransmissionthroughAppearsunlikely1,9–­52
breastmilkCannotberuledoutand/orlimitedevaluationoflikelihood53–­67
Didnotcomment68–80­
BreastfeedingofCOVID+Primarilyencouragedtodirectlybreastfeed10–­13,15,17–­20,24–­26,28,29,33,35–­38,41,42,
orsuspectedmothers:45–­47,49,51,55,56,65–­67,70,71,73,74,76,78
primaryrecommendationsPrimarilyencourageduseofexpressedbreastmilk1,14,39,40,62
andotherconsiderations
Primarilyencouragedtoabstainfromuseofanybreast27,30,32,43,54,58,60,61,69,72,75
milkduringsetinfectiousperiod
Primaryrecommendationsnon-­specificforeitherdirect59
breastfeedingoruseofexpressedbreastmilk
Primarilyencouragedtomakeplanthroughshareddecision9,16,21,31,44,47,50,52,53,57,64,68
makingwithparents
Useofexpressedbreastmilktypicallyonlyifmaternalor10,11,13,15,17,18,24,28,29,35,38,41,42,45–­47,
fetalstatuspreventsdirectbreastfeeding49,56,65–­67
Recommendationofdirectbreastfeedingvsuseof22,23,34,63,77,79,80
expressedbreastmilkbasedonpresenceorabsenceof
symptoms,minimumtimeafebrile,etc
Considerinfantfeedingthroughuseofahealthycaretaker1,14,21,24,29,34,39,40,49,50,52,56,65,66,68
ifmotherissymptomatic,74
However,whilesomeadvocatedforroutineseparationofItwasalsorecommendedthattheamountoftimethatthe
motherandchildimmediatelyafterbirth,somemajornationalandmotherandinfantremainedhospitalizedbelimitedtominimize
internationalhealthorganizationsdidnot, hafter
knowledgewasgainedaboutCOVID-­19andtheneedtobalancethevaginaldeliveryand48–­96 ,19,70Itwas
risksandbenefitsofCOVID-­19preve