When New Moms Have COVID-19

Do the risks of separation outweigh the benefits when trying to avoid SARS-CoV-2 with a new baby?

Breaking News – The AAP has updated their guidance on newborns whose mothers have suspected or confirmed COVID-19. (see below)

Most of us are getting used to the idea of social distancing, staying home to flatten the curve, and the need to enter isolation if we actually get sick with COVID-19.

Isolation separates sick people with a quarantinable communicable disease from people who are not sick.”

Legal Authorities for Isolation and Quarantine

In most cases, even if you are in a home with other people, isolation is doable, as you just stay in your own room and keep away from everyone else.

When New Moms Have COVID-19

What about if a parent develops COVID-19?

Should they stay away from their kids?

Well, yeah. It might seem extreme, but you don’t want to intentionally get your kids sick!

Even if you just had a baby?

“It was devastating when they wheeled in the incubator. It hadn’t occurred to me they would even suggest it.”

New Mom who was treated as a PUI for COVID-19

That’s a tough one!

After all, we know that separating a newborn from their mother has consequences, just as there is a risk that a baby could get infected with SARS-CoV-2 if their mom has it.

The idea isn’t new though.

“If the mother has tuberculosis disease, the infant should be evaluated for congenital tuberculosis (see Congenital Tuberculosis, p 848), and the mother should be tested for HIV infection. The mother and the infant should be separated until the mother has been evaluated and, if tuberculosis disease is suspected, until the mother and infant are receiving appropriate antituberculosis therapy, the mother wears a mask, and the mother understands and is willing to adhere to infection-control measures.”

Tuberculosis – RedBook 31st Edition

We already recommend separating newborns from their mothers if they have active tuberculosis disease.

“The optimal length of temporary separation in the hospital has not been established, and will need to be assessed on a case-by-case basis after considering factors to balance the risk of mother-to-infant influenza virus transmission versus maintaining maternal-infant bonding.”

CDC on Influenza Guidance Prevention & Control in Peri- and Postpartum Settings

And if a mother “is ill with suspected or confirmed influenza,” which is another good reason to get your flu shot if you are pregnant!

“Mother-to-child transmission of coronavirus during pregnancy is unlikely, but after birth a newborn is susceptible to person-to-person spread.”

COVID-19 on Pregnancy and Breastfeeding

So what should you do?

Surprisingly, in this case, the answer depends on who you ask and where you live…

“The determination of whether or not to separate a mother with known or suspected COVID-19 and her infant should be made on a case-by-case basis using shared decision-making between the mother and the clinical team.”

CDC on Considerations for Inpatient Obstetric Healthcare Settings

The guidelines from the Centers for Disease Control and Prevention mentions the “risks and benefits of temporary separation of a mother with known or suspected COVID-19 and her infant,” and offers tips on what to do if separation is not undertaken.

What are the risks of separation?

Well, they don’t actually list any of them, but you might expect them to include:

  • trouble breastfeeding, especially if you are having to pump and someone else is feeding your baby formula or expressed breastmilk with a bottle instead of a supplemental nursing system
  • an increased risk for postpartum depression, especially as a recent stressful event, having inadequate social supports (social distancing makes getting help, even when you have a new baby, hard), and trouble breastfeeding are all risk factors for PPD. In this case, both COVID-19 and the separation would be stressful events that could put a new mother at increased risk for PPD.
  • having difficulty bonding with your baby once you get reunited, especially if it is a long separation

If you are going to make an informed decision, in addition to understanding the risks about your baby developing COVID-19, which can certainly be more severe in newborns and infants, it is important to know the risks of trying to avoid it.

Fortunately, any kind of separation for babies is typically brief.

Not surprisingly, the advice from the American Academy of Pediatrics seems more concrete.

“While difficult, temporary separation of mother and newborn will minimize the risk of postnatal infant infection from maternal respiratory secretions.”

AAP on INITIAL GUIDANCE: Management of Infants Born to Mothers with COVID-19

The INITIAL GUIDANCE from the AAP recommended separation and then, after hospital discharge, that mother’s with COVID-19 “maintain a distance of at least 6 feet from the newborn, and when in closer proximity use a mask and hand-hygiene for newborn care until (a) she is afebrile for 72 hours without use of antipyretics, and (b) at least 7 days have passed since symptoms first appeared.”

“Other caregivers in the home who remain under observation for development of COVID-19 should use standard procedural masks and hand hygiene when within 6 feet of the newborn until their status is resolved.”

AAP on INITIAL GUIDANCE: Management of Infants Born to Mothers with COVID-19

They have since updated that guidance, and while they still recommend separation as the “safest course of action,” because it is a controversial issue and separation has downsides, they now offer guidelines on what to do if mom chooses to room in with her baby.

They still advocate testing newborns if a mother is positive at about 24 hours of age, with repeat testing at 48 hours if the first test was negative.

In parts of the world where clean water is not guaranteed, exclusive breastfeeding might be essential to a baby’s survival. Did that influence the WHO’s guidance?

The advice from the World Health Organization is very different though!

They do not recommend any type of separation.

“Considering the benefits of breastfeeding and the insignificant role of breastmilk in the transmission of other respiratory viruses, the mother can continue breastfeeding, while applying all the necessary precautions.

For symptomatic mothers well enough to breastfeed, this includes wearing a mask when near a child (including during feeding), washing hands before and after contact with the child (including feeding), and cleaning/disinfecting contaminated surfaces – as should be done in all cases where anyone with confirmed or suspected COVID-19 interacts with others, including children.

If a mother is too ill, she should be encouraged to express milk and give it to the child via a clean cup and/or spoon – all while following the same infection prevention methods.”

UNICEF on Coronavirus disease (COVID-19): What parents should know

It is important to note that the WHO isn’t saying that you don’t have to take any precautions! Respiratory hygiene typically includes wearing a mask, as you can see described in the above recommendations from UNICEF, etc.

What about the American College of Obstetricians and Gynecologists (ACOG)?

“To reduce the risk of transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (eg, separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued.”

ACOG Novel Coronavirus 2019 (COVID-19) Practice Advisory

They also recommend separation.

“Mothers with suspected or proven COVID-19 and their infants should not be completely separated. Mothers and infants should be allowed to remain together, after potential risks and benefits of rooming-in have been discussed and allowing for shared decision-making with families and their health care providers. There is some evidence to suggest that infants can be infected with SARS-CoV-2 postnatally.”

Canadian Paediatric Society on Breastfeeding when mothers have suspected or proven COVID-19

In contrast, pediatricians in Canada do not recommend separation!

“Mothers can practice skin-to-skin care and breastfeed while in hospital with some modifications to usual processes. Among the precautions, mothers should don a surgical/procedure mask when near their infant and practice proper hand hygiene before skin-to-skin contact, breastfeeding and routine baby care. Mother and baby should be discharged home as soon as they are deemed ready and then convalesce at home with guidance from the hospital.”

Canadian Paediatric Society on Breastfeeding when mothers have suspected or proven COVID-19

Like the WHO, they simply recommend advanced hygiene.

“If the mother has COVID-19, there may be more worry, but it is still reasonable to choose to breastfeed and provide expressed milk for her infant. Limiting the infant’s exposure via respiratory secretions may require more careful adherence to the recommendations depending on the mother’s illness.”

ABM Statement on Coronavirus 2019 (COVID-19)

It is important to note though that all organizations recommend continued breastfeeding, or at the very least that babies get expressed breastmilk if they are not able to actually nurse if separated from their mothers.

“SARS-CoV-2 has not been detected in breast milk to date.”

AAP on INITIAL GUIDANCE: Management of Infants Born to Mothers with COVID-19

Confused?

“One must weigh the risk of the newborn getting severe COVID-19 infection, which is rare but likely finite, with the risk of undermining the establishment of breastfeeding and the consequences of breastfeeding failure, which can be significant, particularly in low-income settings. Failure to establish breastfeeding could put the newborn at risk of food insecurity and other infections.”

COVID-19: Separating Infected Mothers from Newborns: Weighing the Risks and Benefits

What’s going to happen if you have a baby and you test positive for COVID-19?


UWMC Infant Care Guidelines for COVID-19

You will talk to your health care providers, who will help you make the best decision for you and your baby.

And know that both hospitals and your pediatric provider are well equipped to keep you and your baby safe from SARS-CoV-2.

More on When New Moms Have COVID-19

Chiropractic and Craniosacral Therapy for Breastfeeding Problems

What is the evidence for going to a chiropractor or getting craniosacral therapy when you need help breastfeeding?

Despite what some folks believe, most pediatricians are very interested in breastfeeding and learning as much as they can to help their families breastfeeding effectively for as long as they wish.

They are not looking to push baby formula or bottles to sabotage a mom’s chances of breastfeeding her baby.

It can help you breastfeed if you get ongoing support.
Your pediatrician should give you ongoing support to help you breastfeed effectively.

And they will typically do anything to help the mom breastfeed, as well as make sure the baby is getting enough to eat. At least they will do anything that has some evidence to show that it is effective.

Chiropractic for Breastfeeding Problems

Will they refer their babies to a chiropractor for extra help with breastfeeding?

“Chiropractic manipulation in children who are < age 12 years is considered unproven and not medically necessary as a treatment for any diagnosis as there is insufficient published evidence to assess the safety and/or impact on health outcomes in the pediatric population.”

Chiropractic Spinal Manipulation in Children

Probably not, as there is no real evidence that it would help. Unfortunately, well meaning pediatricians do often refer their patients to lactation consultants who may then recommend further management by a chiropractor.

Why?

“Based on their case studies and the volumes of previous research, these researchers concluded that subluxations and the neurological interference they cause play a major role in Hypolactation. The researchers suggest, “Chiropractic evaluation for subluxations would be a key element in the holistic assessment of the failure to establish milk supply in the post partum patient.””

icpa on Chiropractic Helps New Mothers Produce Milk

Maybe it is because they don’t understand that when chiropractors use the term subluxations, they are not referring to something you can see on an xray, but rather something they think they can feel, and when manipulated, unblocks the flow of energy that prevents your body’s innate ability to heal itself.

“DD Palmer, an American magnetic healer, believed that diseases are often caused by subluxations of the vertebrae, which, in turn, lead to an interruption of nervous impulses; and that the correction of these subluxations allows the body to heal itself. This is still a central tenet of chiropractic.”

Chiropractic care for children: Controversies and issues

Is that why your baby is having trouble breastfeeding? An invisible subluxation is blocking the flow of energy in your body?

Or is that why your baby has reflux or colic?

I doubled checked my copy of Gray's Anatomy, and our nervous system and the things it supplies don't look like this. The gall bladder, for example, is supplied by the vagus nerve (Cranial Nerve X) and the phrenic nerve (cervical nerves 3 to 5) and is not associated with the T4 vertebrae.
I doubled checked my copy of Gray’s Anatomy, and our nervous system and the things it supplies does’t look like this. The gall bladder, for example, is supplied by the vagus nerve (Cranial Nerve X) and the phrenic nerve (cervical nerves 3 to 5) and is not associated with the T4 vertebrae.

What about the “research” chiropractors talk about?

They are case studies, which is basically a chiropractor telling a story (glorified anecdote) about what happened to their patient, without any evidence of why it happened or how it could have happened.

“High-quality evidence supporting effectiveness of spinal manipulation for nonmusculoskeletal concerns is lacking, especially in infants and children, for whom the risks of adverse events may be the highest because of immature stability of the spine.”

AAP on Pediatric Integrative Medicine

The American Academy of Pediatrics Section on Integrative Medicine even warns parents about taking their kids to a chiropractor. And that’s saying something, as they promote some other holistic therapies that aren’t actually all that evidence based.

Craniosacral Therapy for Breastfeeding Problems

What about craniosacral therapy?

Similar to chiropractic, it has to do with has to do with tides and rhythms of cerebrospinal fluid, which these practitioners think they can feel and manipulate by massaging your baby’s head.

Is that why your baby isn’t breastfeeding well? The tides and rhythms of his cerebrospinal fluid are off?

“When a baby is unable to nurse or nurses so poorly that he causes pain to his mother, he presents a true challenge. A mother who experiences pain or who perceives that her baby is not breastfeeding effectively is a mother who is at risk of prematurely weaning this baby.

After working through all of the usual avenues of information and resources that can help in this kind of situation, some Leaders have found a new therapy, called CranioSacral Therapy (CST), can be helpful. CST is a light-touch manual therapy used to encourage the body’s self-correcting mechanisms.”

La Leche League on Considering CranioSacral Therapy in Difficult Situations

Not surprisingly, there is no real evidence that craniosacral therapy helps breastfeeding or anything else.

It is very surprising that some parents are willing to pay $600 or more for a few craniosacral therapy sessions.

And it is disappointing that a lactation consultant would refer their patients for this kind of therapy, since there is no evidence that it will work.

What to Know About Chiropractic and Craniosacral Therapy for Breastfeeding Problems

Parents looking for breastfeeding support should view a referral to a chiropractor or to get craniosacral therapy as a red flag and consider getting a second opinion for their breastfeeding problems from someone who uses evidence based therapies that have been proven to work.

More on Chiropractic and Craniosacral Therapy for Breastfeeding Problems

The Breastfeeding Elimination Diet for Fussy Babies with Allergic Colitis

A breastfeeding elimination diet can be helpful if your baby is overly fussy and might have a milk protein allergy or intolerance to other foods that you are eating.

What should you do when your breastfeeding baby gets fussy?

Your Fussy Baby

Babies cry. Talk to your pediatrician if the crying seems to be excessive, especially if you have a hard time consoling your baby.
Babies cry. Talk to your pediatrician if the crying seems to be excessive, especially if you have a hard time consoling your baby. (CC BY 2.0)

Like a formula fed baby, you should make sure your fussy breastfeeding baby isn’t hungry and doesn’t have a fever, colic, reflux, teething, an upper respiratory tract infection, and all of the other things that can make them fussy.

After eliminating those, and seeing your pediatrician to make sure that your baby has been gaining weight well, it might be time to eliminate things from your diet, as your baby might have allergic colitis (protein-induced colitis).

This is especially true if your breastfeeding baby is fussy, extra gassy, and has foul smelling, green, mucousy stools. You might also notice streaks of blood in your baby’s stool or that your baby has bad eczema already.

While babies can’t be allergic to your breast milk, they can certainly be allergic or intolerant to any number of things that you eat or drink and which enter your milk.

Foods To Eliminate First

Even before you start to think about foods to eliminate from your diet, please keep in mind that this isn’t a reason to stop breastfeeding and switch to formula. Since most formula is based on cow’s milk, your baby will likely continue to have problems on most routine formulas. Some babies even continue to have problems drinking an expensive hydrolyzed protein formula (Alimentum or Nutramigen) and have to move to an even more expensive elemental formula (Elecare, Neocate, or PurAmino).

Once you do begin to think about eliminating foods from your diet, you should probably start with milk and diary foods. Those are the most likely to cause issues with your baby, either an allergy or intolerance. And they are probably the easiest to avoid. If supplementing with some formula, be sure that it is milk and soy free. A hydrolyzed protein formula (Alimentum or Nutramigen) would usually be a good first choice.

The Breastfeeding Elimination Diet

If that doesn’t work, you can continue to eliminate other foods or foods groups from your diet, one at a time until you find what is triggering your babies symptoms, including:

  • soy
  • citrus fruits
  • eggs
  • nuts
  • peanuts
  • wheat
  • corn
  • strawberries
  • chocolate
  • fish and shellfish

The Academy of Breastfeeding Medicine recommends that after eliminating a food or food group, breastfeeding moms “wait a minimum of 2 weeks and up to 4 weeks,” although they should see improvement much sooner, within 2 to 3 days.

A Faster Breastfeeding Elimination Diet

Eliminating one food group at a time and waiting to see if it works can take time. A faster, but much more extreme approach is to eliminate most high-allergen foods all at once.

So what do you eat on this restrictive diet?

On this type of low-allergen diet, a breastfeeding mom might end up only eating foods like lamb, pears, squash, and rice. Other foods in this type of total elimination diet might also include chicken and turkey, potatoes, apples, and bananas.

Once your baby’s symptoms resolve, you can then slowly start introducing foods back into your diet, one food or food group at a time each week. Of course, stop a food if your child’s symptoms come back after it is reintroduced into your diet.

After avoiding a problem food for about six months and once your infant is 9 to 12 months old, you can likely reintroduce it into your diet and watch for symptoms

Another option, before trying the total elimination diet, might be to avoid milk, soy, fish, shellfish, and wheat. Then go total if that doesn’t work.

More About Breastfeeding Elimination Diets

Remember that once your baby is better and you are back on a fairly regular diet, simply avoiding the one or two foods that your baby can’t tolerate, it is still possible that your baby will be fussy sometimes. While it could mean that you ate something you weren’t supposed to, it also mean that you baby is teething, has a cold, is off her schedule, has developed reflux, or any number of other things. It’s not always going to be about food issues.

Also keep in mind that:

  • you should take vitamins (in addition to your daily prenatal vitamin, you will likely need extra calcium) to make up for anything you are missing in your elimination diet, especially calcium, vitamin D, iron, and folate, etc. and make sure you are getting enough protein and calories
  • missing the hidden ingredients in foods are likely a big reason why babies continue to have symptoms while you are following an elimination diet (for example, milk can sometimes be found as an ingredient in luncheon meats, many baked goods, and many other nondairy products) – check food labels and understand how to identify hidden ingredients in foods
  • lactose free cow’s milk, low fat cow’s milk, and other animal milks, including goat milk, are not good substitutes if you are trying to avoid cow’s milk in an elimination diet. Even soy milk and other soy products can often cause similar reactions. You also should try and make your own, homemade baby formula.
  • some vitamins and supplements can be a source of hidden milk, soy, and wheat
  • after avoiding a food for about six months and once your infant is 9 to 12 months old, you can likely reintroduce it into your diet and watch for symptoms
  • a registered dietician can help manage make sure you are getting all of the nutrients you need on this restrictive diet
  • in addition to your pediatrician, a pediatric gastroenterologist can also help manage your baby with allergic colitis, especially  when you need to follow a total elimination diet

Fortunately, allergic colitis is not common, so few breastfeeding mothers should have to try, or stick with, any of these types of restrictive diets.

And since some studies are showing that babies who just have some rectal bleeding don’t even have allergic colitis and that their symptoms go away without any interventions, make sure your baby’s symptoms actually warrant these types of treatments.

What To Know About Breastfeeding Elimination Diets

A breastfeeding elimination diet can be helpful if your baby is overly fussy and might have a milk protein allergy or intolerance to other foods that you are eating.

More Information on Breastfeeding Elimination Diets

Breastfeeding Recommendations

The AAP recommends exclusive breastfeeding for about six months and to continue for at least the first year.

Parents often have a lot of questions about breastfeeding.

One thing that they shouldn’t question is that breastfeeding provides a number of “short- and long-term medical and neurodevelopmental advantages” for their baby.

That’s why the American Academy of Pediatrics, in their 2012 policy statement on Breastfeeding and the Use of Human Milk recommended:

“Exclusive breastfeeding for about six months…”

And for breastfeeding “to continue for at least the first year and beyond for as long as mutually desired by mother and child…”

Since the AAP has concluded that “breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development,” be sure you get all the help you need to effectively breastfeed your child.

And remember, if breastfeeding was easy, we wouldn’t need lactation consultants. So don’t be afraid to ask for help.

For more information: