Few people want to go into a hospital these days. They are fearful of infection by the coronavirus.
But what about women who are giving birth?
Many are asking that they be released from the hospital as soon as possible after delivery. Although that’s OK for some, there are concerns.
To learn more about it, we spoke recently with Joanna Parga-Belinkie, an attending neonatologist at Children’s Hospital of Philadelphia.
Are parents asking to be discharged with their newborns sooner than usual because of the coronavirus?
Typically, before the pandemic, discharges for vaginal deliveries without complications would be in about two days. For C-section deliveries, it would be three to four days.
Now, the short answer is yes, parents want to get out as soon as they can. Part of it is that they don’t like that no one can visit. Just the mom and whoever she has designated to be her support can be there.
But they are also scared to be in the hospital. They are worried about disease because they know that people with COVID-19 are going to the hospital. In general, they are concerned about the pandemic, and who can blame them?
Are you able to allow that?
We have concerns about discharging babies too early because we don’t want to miss any serious conditions. Also, we don’t want babies to be discharged and then rehospitalized soon afterward.
The American Academy of Pediatrics [AAP] has not changed its recommendations for the safe discharge of newborns. The recommendations were made to ensure that an infant is adapting to life outside the womb and that the mom has recovered and is well-supported in things like breastfeeding.
Before babies leave, we want to make sure that they have normal vital signs, things like pulse or heart rate and respiratory rate. We do screening to evaluate them for infection. We want to make sure they have had two successful feeding episodes and have voided and defecated — or, peed and pooped. We want to make sure that they are getting vaccines, particularly hepatitis B. We need a plan to follow up for jaundice. And we need to do other screening tests that cannot be done before the 24-hour mark.
Our general guideline now is that we would like the babies to stay for at least 24 hours. That’s the earliest I generally feel comfortable discharging anyone.
A lot of moms want to go after that 24-hour mark. If it looks possible, at 24 hours we say, “OK, let’s get all their screenings done.” It will take a few hours to get the results. And then, unless the results are abnormal, they often can go home.
I worry a little more about first-time moms. I want to make sure they are getting the education and support they need. It’s a tough time to be delivering because so many health services are changing. A lot of pediatricians’ offices have more strict policies when visiting. A lot more practices are doing a lot more telemedicine, which is becoming so much more important to pediatric care.
One Penn initiative to support families after they leave the hospital is called “Healing at Home.” It’s a virtual platform, where parents get counseling and support, including lactation support. We’re trying to enroll more moms in that.
Tell us about the screenings.
They include the newborn screen, the hearing screen, and the critical congenital heart disease, or CCHD, screen.
The newborn screen tests for things like hormonal, metabolic, and genetic conditions. Essentially, right after delivery, the baby is changing fast. There are a lot of hormone changes and electrolyte changes, etc., and all this can affect the screen. So the state, which requires the screen, doesn’t even accept one that has been done before 24 hours. Doing it early means that it must be repeated, and some outpatient pediatric practices aren’t used to or equipped to send a newborn screen.
The CCHD screen looks for different heart conditions. Also, all babies have an extra blood vessel — called a patent ductus arteriosus, or PDA for short — that usually closes up to 36 hours after they are born. It’s considered persistent if it stays open for longer than 72 hours, and it is something we monitor for.
As for the hearing screen, it’s easy to fail that test in the first 24 hours. The baby goes from a fluid environment to air, and it takes time for the ear canal to adjust. If the baby fails the hearing test, our only recourse is to do an audio referral, and that can take about a month. So we’d much rather wait 24 hours to do the hearing test.
Another thing we monitor for is jaundice, which is common in the first few weeks of life, especially in babies that are being breastfed. We can often find out who might be at risk for jaundice when they are in the well-baby nursery after delivery. It helps us to check those levels after 24 hours to see how they are trending.
Does an early discharge make it more important to visit a pediatrician soon?
I always want any baby to see their pediatrician within 48 hours of leaving the hospital. In some cases, I’ll advocate for seeing the pediatrician in a day’s time. Babies tend to lose weight in the first week of life, and that needs to be monitored closely.
But it’s not just for the baby. It’s also for the mom to get support, such as lactation support and mental-health support. The health of baby is often tied to the health of mom.
As a well-baby attending physician, I’m seeing the infant for just a few days. But the pediatrician is going to be the one following them through their lives. Establishing that connection early on is important.
Now, with COVID-19, we’re streamlining care from the inpatient to the outpatient world. A silver lining in all this is that it’s going to challenge us to make a more integrated health-care system. There are so many separate pediatricians’ offices, and when I discharge a baby, I may not know some offices as well as others. But now, I’m starting to engage with a lot more practitioners. There is more interconnectedness. That could lead to me changing my practice and feeling more empowered to discharge mothers earlier.
Are moms more worried about breastfeeding now?
Breastfeeding is a wonderful and natural thing, but it’s not necessarily intuitive. It takes time to establish a successful breastfeeding relationship. Again, I worry about new moms. I want to make sure they are getting the breastfeeding support that they need.
As far as viral transmission of COVID-19 through breast milk, we don’t think it happens. Researchers have tested the breast milk of mothers who had COVID-19 and delivered, and they did not find the virus. That is why organizations like the AAP, Centers for Disease Control and Prevention, and the World Health Organization are encouraging moms to continue to use breast milk as nutrition for their infants.
That said, if a mother is sick with COVID-19 or suspects she may be, they also recommend precautions. If a mom is directly breastfeeding, she should wear a mask, wash her hands before and after handling the baby, and enlist a support person to watch the infant when she is not feeding.
We’re in a dynamic time with COVID-19 because we’re still learning so much about it. Currently, the AAP recommends separation of mom and baby if the mom is infected. It is the best way to ensure that the infant doesn’t get infected. But the recommendations may change. We have to be thoughtful about how we counsel families so that moms feel supported. If they want to breastfeed — or do skin-to-skin — moms need to be very mindful of infection control.
All of our goals are to try to decrease as much as we can the spread of the virus between mom and baby.