Newborn Isolation, COVID-19 CDC Guidelines, and Infant Mental Health

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Under what circumstances would you consider never holding your newborn baby, depriving yourselves of that golden hour of brain development and optimal attachment?  What would the circumstances need to be for you to choose that separation and all of the grief and consequences for two weeks? That is exactly the choice many American birthing parents who are ill with COVID-19 are facing. 

While the World Health Organization (WHO) recommends keeping the birthing parent and their baby together and actively breastfeeding (while using precautions), the US Center for Disease Control (CDC) recommends treating the newborn as a person who may have the illness with isolation from their parents for two weeks. Currently they may receive breastmilk through an alternate feeding method. Any caregivers must be gowned, gloved, and masked, and not have the illness. I checked extensively through social media and private email platforms of perinatal organizations, and found that hospital guidelines are mixed. Some don’t have room to isolate an infant for two weeks and are defaulting to the WHO guidelines. So if you are birthing in a small hospital and are ill, you are likely to keep your baby.

However, many larger hospitals in the USA are prepared to follow the CDC recommendations and have written two weeks of newborn separation into their guidelines.

Just like an adult’s, newborn’s brains are affected permanently by separation and loss; it’s something that has been studied scientifically for over fifty years. However recovery and repair are also possible. Infants are incredibly fragile and incredibly resilient.  As parents and counselors to parents, we want to protect children as much as possible. When bad things happen we are willing to do what is needed to ameliorate their effects. 

The problem now is that parents may have the decision made for them, may be pressured into separation, or may make the choice without fully understanding the consequences. Lastly, they may not understand the lasting effects on the newborn’s brain and developing mind (psyche) and not act to repair those consequences. 

April 16 Update: Pressure from people like me and other professionals and organizations has worked! The CDC now recommends shared decision making between parents and providers. The American Nurses Association has created a document to help nurses to advocate for the choice parents want and care pathways for each choice.  See Nurse Advocacy during COVID19.  Read more to find out why this is a US issue and not a worldwide one. 

Are Medical Professionals Making The Decision or Are Parents?

In discussions with certified nurse-midwives, they see their role as guiding parents into the right decision for them.  In many instances their position was this: “There is so much we don’t know about the disease, and the parents will be bearing the consequences of any decision. So they should be the ones making the decision.” 

Other perinatal professions and hospital administrators do not see it that way, but instead take on the mantle of authority. The American College of Obstetrics and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) state the newborn should be treated following the CDC guidelines. However, this is a healthy baby and the obstetric and maternal fetal medicine areas of expertise end once the umbilical cord is cut. Pediatricians are the medical experts but so far the American Academy of Pediatrics (AAP) has stayed silent on this particular issue, deferring to the CDC guidelines on it’s web pages and blog.[i] If physicians who are used to an autocratic decision making style impose their beliefs on their patient and separate the newborn without a lengthy discussion with parents, that is not good medical care. They do not have to live with the outcomes of this decision, and the consequences of two weeks of separation at this developmental stage are lifelong.

04/07/2020: Evidence Based Birth has added a consent form for parents to use on their COVID19 information page 

Is it medically ethical for physicians to make this decision for a family?

Anytime a decision may have a negative outcome for a person or group, or it goes beyond legality or efficiency, then ethics are involved. Ethical choices involve human rights, what is just, what is virtuous, as well as what is for the common good. In this way, it is definitely an ethical dilemma and one that ought to be made by the parents, not the health care provider.

I am concerned about parents who are not being given the choice as well as those who do not understand all of their options – people who are regularly marginalized and seen as not capable of making “good choices” by those are in authority.  This is most often along the lines of Medicaid status, perceived race, ethnicity, income, education, disability, mental illness, or citizenship.  Parents who are well resourced, and similar in ethnicity and background to the health care provider are more likely to have more leeway in making their own decisions. They are also more likely to have a contrary decision respected by authority. Stories are already circulating from major American cities that Black birthing people are receiving worse care and treatment than usual. Both ACNM and AAP have spoken out on their concerns that professional members do not show bias in their care during the pandemic. Even the NAACP has written a special paper on the equity implications of the coronavirus epidemic in the U.S. 

 Isolation of the newborn without adequate understanding of their options, including the fact that the rest of the world isn’t doing this, needs to be part of the family’s decision making.  All choices, including isolation or keeping the family together deserve respect and support. Parents should also be allowed to change their minds. 

What are the risks?

From what we know about COVID-19, healthy newborns in China did not die or require NICU treatment (n = 9). But that doesn’t mean the symptoms are always mild.  The illness can bring feeding problems, dehydration, and pneumonia (not requiring ventilation).  Most importantly we do not know the long-term effects of having a coronavirus in infancy. For example, my youngest child got the chicken pox virus at four weeks of age (along with their older siblings). They only had about six pox and didn’t seem very bothered by the illness.  However, they did get four outbreaks of shingles before adolescence. In adulthood, they have more immunity against shingles and other herpes viruses. With COVID-19, parents are making the decision to isolate or not based on a lack of information.  There is so much we don’t know and can’t guess.

The mental health risks to the infant are tangible and real when separated from their mother. The infant brain does not know how to process the loss, only that the loss exists.  It draws the only conclusion that it can, the mother must be dead, and begins the biochemical process of grief.  During an optimal postpartum, infants are held skin to skin, talked to with eight to ten inches of eye contact, and are tended to sensitively and quickly by their parents.  The parents get to know their child and the changes in the parental brain begun during pregnancy ramp up during the postpartum through interaction with the child.  The child in turn, learns to regulate their emotions, sleep patterns, and develops an observable rhythm in their communications.  They move in sync to the conversations around them, fitting in more and more into the environment in which they find themselves.

Infants who are isolated and without parental contact are still going through those same adaptive processes. However they are adapting to the hospital environment and routines. In the hospital shift work, they likely will have multiple caregivers who may not be available when the infant needs care. Their brain maturation and patterns are altered because the caregiving is inconsistent, and people caring for them are masked and gowned. They do not see faces or hear the sounds of their home or the womb. This deprivation from the optimal environment can make temperature regulation difficult and lead to a lowered immune system response.

All the parents and the child are experiencing a death. It's a death of their ideal postpartum time and that is what the physical body and the brain experiences – a loss.  Our minds can try to rationalize out those feelings, telling us stories that help us to cope.  That is a strategy adults have available that infants do not. Their mind is not mature enough to help interpret what their brain is telling them; at this time of life both are the same. 

Is this a human rights issue or a medical decision?

In their position paper on the Rights of Infants, the International Association for Infant Mental Health indicates that the infant has a right to have their mental health and future life consequences as part of any health care decision. In examining the document, the WIAMH white paper would find the CDC guidelines to be in violation of their dearest principles.  The consequences of COVID-19 are not dire enough to violate an infant’s human right to optimal developmental and parental care in the postpartum period.

It is worth noting that nowhere else in the world are medical professionals recommending isolation of the newborn from their parent, this is happening uniquely in the United States. Canada is also following the WHO guidelines. 

Why do the WHO and the CDC guidelines differ from one another?

First, the WHO is deciding best practices for first, second, and third world countries.  Nations that do not have a lot of resources and nations that do are in the same group.  The US is a developed, wealthy country and larger hospitals would have the resources to isolate and care for newborns separately.  Second, the WHO creates policies for nations that have many philosophies, some that are more collectivist and interdependent that our own. In the United States, we value independence, self-reliance, and put our infants to sleep away from the rest of the family. Isolation of the infant resonates with American cultural values, otherwise it would never be seen as a solution.  We also have a very high tolerance for violence and injury in the United States. Third, causing emotional harm is seen as less injurious than physical harm, rather than seeing them as equally valid.

To go further, the medical professionals who are making the decision for the parents will likely never see them again and will never know the outcomes. When you are divorced from the consequences it becomes easier to make choices that veer towards the consequences you can see (not getting a respiratory virus) rather than the ones you can’t (infant loss and grief, misaligned emotional regulation processes, lack of trust in the world and that you matter). 

If parents or doctors do decide to separate the infant and parents, are the consequences lifelong?  Can their relationship be repaired? Are there strategies to help? 

YES! What we have learned from many adults seeking therapy for infant loss and separation issues and from parents of Neonatal Intensive Care Unit (NICU) hospitalized children is that we can recover. With intentional loving strategies that are paced to the needs of the infant, trust can be regained, and interrupted brain processes can be restored. This requires effort on the part of parents, learning how the infant’s brain and mind work, and a commitment to prioritize the infant’s mental health over the next several months.  But a healthy parent-child relationship can be re-established after separation.  (See my next blog post.)  We can help infants to heal from loss and learn to trust in their parents and medical personnel again. 

[i] From an anthropological perspective, the larger the institution the more it reinforces the values of the majority culture. This includes a sense of entitlement to influence parenting decisions that are made on their property (hospitals, schools, jails, etc) to also reinforce the majority culture norms. 

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