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Am J Perinatol 2020; 37(S 02): S1-S4
DOI: 10.1055/s-0040-1714255
Editorial

Skin-to-Skin Contact at Birth in the COVID-19 Era: In Need of Help!

Riccardo Davanzo
1   Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
,
Anne Merewood
2   Division of General Pediatrics, Boston Medical Center, Boston, Massachusetts
,
Paolo Manzoni
3   Division of Pediatrics and Neonatology, Department of Maternal Infant Medicine, “Degli Infermi” Hospital, Pomderano, Biella, Italy
› Author Affiliations Funding None.
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Skin-to-skin contact (SSC) between mother and neonate at the time of delivery and more generally in the very early life is a practice recommended by International Health Authorities[1] and Scientific Societies.[2] A naked (except for a diaper and possibly a cap) baby is placed on the mother's abdomen/chest (in case of a vaginal birth) or on the mother's chest (in case of a cesarean delivery) and a blanket is routinely draped over both of them to ensure thermal control.

Besides, its implementation among healthy infants in the delivery room and on the postpartum wards, SSC is also valued for preterm/low birth weight infants as a component of kangaroo mother care (KMC).[3] Although SSC and KMC were promoted in industrialized countries mainly to facilitate maternal–infant bonding or to psychologically rebalance the impact of a premature birth, in the past 20 years, a solid body of research has shown that SSC and KMC carry also multiple, additional biological, and physical benefits to babies, as well as to their mothers.

Specifically, healthy term babies undergoing SSC achieve body temperature stabilization more efficiently than when using radiant warmers, have decreased crying time, have higher blood glucose levels, show greater relief of symptoms after painful procedures (such as a heel stick for blood sampling), and tend to adapt sooner to extrauterine life, as indicated by their heart and trend of breathing rates.[4] Of note, mothers experiencing SSC tend to deliver the placenta in a shorter mean time compared with mothers who do not experience SSC and show reduced bleeding. Positive, long-term effects of SSC include enhancement of full establishment of a healthy intestinal neonatal microbiome, promotion of maternal–infant relationship, and more effective breastfeeding.[5]

Although the 2018 WHO–UNICEF (World Health Organization– United Nations Children's Fund) revised version of the Baby Friendly Hospital Initiative has reaffirmed the relevance of immediate, continuous, and uninterrupted SSC at least until after the first feed to promote breastfeeding,[1] several inconsistencies in the practice exist and persist worldwide.[5] These inconsistencies include delayed start of SSC, short duration, or even absence of implementation of this practice, mostly after a cesarean section (CS).[5]

More recently, the implementation of SSC has also been hindered by misplaced emphasis on possible association with sudden unexpected postnatal collapse (SUPC) in the early neonatal period, especially in the first 2 hours after birth among apparently healthy newborns.[6] These safety concerns around SSC by health care professionals have been mitigated by interventions aimed to reduce the incidence of SUPC, by providing relevant information to families, and developing specific checklists for the clinical assessment of the neonate.[7] [8]

The practice of SSC has clearly overcome many cultural and implementation barriers so far. The novel coronavirus disease 2019 (COVID-19) epidemic represents the most recent, and at the same time, the most challenging hurdle for SSC, due to concerns on the transmission of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), particularly in the delivery room. Indeed, the COVID-19 pandemic has prompted sudden, abrupt changes in several hospital practices in the area of neonatal care, including management of mothers and infants in delivery room. Due to the lack of evidence, some of these changes have been implemented on the basis of a “first-do-no-(possibly)-harm” driver. It is paradigmatic that in many hospitals in Italy, the United States, and also in other countries worldwide, SSC between mother and her neonate has been no longer allowed during the COVID-19 emergency.

It is understandable that a specific approach in the clinic may be embraced early in an emergency, when in-depth scrutiny might not be feasible. However, as the situation progresses, we must assess the actual risks (if any) for SSC, in the light of the known modalities of transmission of COVID-19. To date, neonates diagnosed with COVID-19 infection are very few, and for all of them horizontal (rather than vertical) acquisition from the mother has been suspected. Obviously, the risk of horizontal transmission cannot be null, unless COVID-19 positive mothers are routinely separated from their infants at birth, and remain so until the end of maternal infectivity. This would require a rigorous (and possibly rigid) model of postpartum management, which is not sustainable or humane from an organizational or psychological point of view.

After all, SSC at birth is only the first of the very many moments when a mother or other family member could transmit the SARS-CoV-2 to her baby. It is more appropriate and pragmatic to endorse and strengthen the use of adequate measures of preventative hygiene, rather than separating mother and neonate over time, and prohibiting practices that are naturally inherent to childbirth.

One additional way to tackle this issue is to examine past experience for scientific guidance originating from similar viral outbreaks, although we are aware that variations in morbidity and mortality between different infectious diseases might have tailored the epidemiological approach for each specific situation. To our knowledge, when the 2009 H1N1 flu (swine flu) pandemic occurred or when the SARS and Middle East respiratory syndrome (MERS) epidemics spread, no major concerns regarding SSC were raised, nor were changes advocated for in infant feeding practices,[9] [10] while preventive measures of acute respiratory infections were constantly indicated. Indeed, during the Spanish flu, it was noted that one reason for susceptibility in children was loss of a mother and loss of access to human milk.[11] Indeed, separation of the mother–infant pair, which de facto precludes SSC and formula feeding were recently recommended by WHO only in the context of the Ebola epidemic.[12]

At the beginning of the current COVID-19 epidemic, the available recommendations on SSC were controversial, at the same time supporting,[13] contraindicating, or just omitting[14] [15] SSC. Consequently, operational uncertainties on the safety of SSC in the delivery room have led to the application of extreme protocols.[16] [17] In reality, concerns that SSC might be a risk factor for SARS-CoV-2 transmission from a COVID-19 mother to her neonate are denied by the lack of both evidence and biological plausibility. SARS-CoV-2 is not detectable in the amniotic fluid of COVID-19 women,[18] [19] nor in the vaginal fluid of COVID-19 pregnant woman at childbirth.[20] Additionally, should SARS-CoV-2 be detectable on the skin of a COVID-19 positive mother? We can consider both the bioaerosol[21] and orofaecal[22] transmissions of SARS-CoV-2 from the mother to her neonate during intimate skin contact at the moment as the only hypothesis to be confirmed. Moreover, at birth, neonates can still take advantage from the protective effect of the vernix caseosa. Finally, we should appreciate that in most cases, a neonate with postnatal SARS-CoV-2 infection is unlikely to suffer adverse consequences,[16] except in the context of preterm delivery, which is elevated in the pregnant COVID-19 population.[23]

Many current guidelines issued worldwide by Neonatology and Perinatology Societies recommend that COVID-19 positive mothers can breastfeed, unless they are unable to do so due to severe forms of COVID-19 disease.[15] [24] [25] It is inconsistent to recommend against SSC when, in the same woman, breastfeeding is encouraged. Only sick mothers who are physically unable to perform SSC should be excluded from the practice, thus in line with the above-mentioned framework of recommendations for breastfeeding.

The WHO has released detailed guidance recommending SSC immediately following birth to continue[26] and now also recommends that the breast needs only to be washed before breastfeeding if the mother has coughed on the breast.[27]

Following new knowledge on perinatal COVID-19 in the course of the current pandemic, scientific societies are expected to legitimize and incorporate SSC into their indications for clinical practice[13] [15] [24] [25] [28] [29] [30] [31] ([Table 1]), as recently also decided by the Italian Society of Neonatology.[29]

Table 1

Selected 2020 indications on postpartum practices for the management of the COVID-19 mother and newborn infant pair

Country, Society, date of issue

Rooming- in

Breastfeeding

Skin-to-skin contact

China. Working Committee on Perinatal and Neonatal Management for the Prevention and Control of the 2019 Novel Coronavirus Infection. February 2020[28]

Routine separation of mother and neonate

No

No

France. Société Francaise de Néonatalogie & Sociéte Francaise de Pédiatrie. March 16, 2020[15]

Mother and neonate stay together except certain limited situations

Yes

Not mentioned

Italy. Società Italiana di Neonatologia. Union of European Neonatal and Perinatal Societies. April 3, 2020,[24]

Encouraged, unless the mother is too sick to care for her baby

Yes, also direct, following infection control measures

Not mentioned in Version 1.

Encouraged in Version 3 (May 10)[29]

Spain. Sociedad Espanõla de Neonatologia. Version 6.0.

April 13, 2020[30]

Separation of the newborn from the mother after birth should be avoided, although the decision to maintain joint accommodation must be made on an individual basis

Yes

May be allowed

Canada. Canadian Pediatric Society. May 6, 2020[25]

Mothers with suspected or proven COVID-19 and their infants should be allowed to remain together

Mothers with suspected or proven COVID-19 are advised to continue to breastfeed. Women who choose to breastfeed should wear a mask and wash their hands prior to placing their infant on the breast. Mothers may also choose to pump, ensuring that they wash their hands, and clean all equipment and then feed their infant expressed breastmilk

Mothers can practice skin-to-skin care

United Kingdom.

• Royal College for Pediatric and Child Health and the British Association of Perinatal Medicine. June 3, 2020[31]

• Royal College of Obstetrics and Gynecology. June 4, 2020[13]

While difficult to separate mother and infant, this is the safest action, at least temporarily

After appropriate hygiene, mothers can express breast milk, which may be fed to the infant by an uninfected caregiver

Not mentioned. Infants should be bathed

USA. American Academy of Pediatrics. July 23, 2020[14]

Well babies born to suspected/confirmed COVID-19 mothers and who do not require medical intervention should remain with their mother in their designated room

Yes, for well babies of COVID-19 suspected or confirmed mothers. The benefits of breast feeding outweigh any theoretical risks

If it is her choice, mother can stay skin to skin with her baby, provided he/she is well[a]

Abbreviation: COVID-19, novel coronavirus disease 2019.


a Specified by the RCOG rather than the RCPCH.


Obviously, after SSC being included in clinical guidelines and protocols, further steps toward its implementation are needed. Women and families should be appropriately informed by health professionals factually committed to SSC, avoiding ambiguity or deterring message, so that the shared decision-making process should be substantial.

In conclusion, as no data, to date, support an increased risk of SARS-CoV-2 contagion of the neonate following SSC after delivery of a COVID-19 positive mother,[32] we advise that SSC continue to be practiced, as recommended by the WHO for all women, including those positive for COVID-19, as far as mothers can carefully follow measures for infection prevention. Ultimately, in the COVID-19 era, SSC, as other natural birth practices, needs not only the scientific evidence, but also the positive attitude of health care professionals to succeed.



Publication History

Article published online:
09 August 2020

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