CDC airs flu guidelines for labor and delivery settings

Nov 17, 2009 (CIDRAP News) – After input from professional groups, the US Centers for Disease Control and Prevention (CDC) recently updated its guidance for managing pandemic flu in labor and delivery settings, relaxing some restrictions on keeping sick moms from their babies.

In revised guidance released Nov 12, the CDC said babies born to mothers who have the pandemic H1N1 virus are no longer considered infectious but rather exposed to the virus. However, the new document keeps in place a recommendation that women who are sick wear a surgical mask during labor and delivery, if they can tolerate one.

The CDC issued its first pandemic guidance for labor and delivery settings in early July, but in late September, during a clinicians conference call, said it was working on revisions because some healthcare providers and their patients were struggling with certain of the elements, such as the recommendation to separate a sick mother from her newborn.

During a clinicians conference call today to review the new guidance and give information on how to handle a range of pandemic flu issues that can arise, Wanda Barfield, MD, MPH, from the CDC's division of reproductive health, said the CDC received feedback on the previous version during professional meetings, conference calls, and outreach to pediatricians, lactations consultants, and public health officials.

She said babies are vulnerable to the virus because their immune systems aren't fully developed, they need constant close contact, and they are potentially exposed to infected caregivers, healthcare providers, or siblings. However, Barfield said the new guidance is still very cautious and is consistent with previous infection control recommendations while providing more flexibility based on hospital configuration, staffing, and surge capacity.

Sonja Rasmussen, MD, a senior scientist in the CDC's division of birth defects and disabilities, said pandemic flu trends continue to suggest a higher fatality rate in pregnant women. As of Aug 21, 28 pregnant women in the United States have died of pandemic H1N1 infections, she said. Those deaths make up 6% of nation's deaths from the disease, though pregnant women make up only 1% of the population.

The CDC continues to strongly urge early antiviral treatment for pregnant women with suspected H1N1 infection, without waiting for testing or test results, and they have placed this high-risk group at the front of the line to receive the first pandemic H1N1 vaccine doses.

Previous guidance recommended that the ill mother avoid close contact with her baby until she had been on antiviral medication for 48 hours, was fever-free, and could control coughs and secretions. They stipulated that until these conditions were met, the newborn receive care in a separate room from a healthy caregiver.

The revised version recommends only a temporary separation and says newborns can stay in the mother's room in an isolette or a bassinette placed more than 6 feet from the sick mother and with a curtain or plexiglass barrier. The CDC said newborns can be kept in the nursery with standard precautions unless they have suspected H1N1 infection.

Babies of ill mothers who are febrile, have been on antivirals for less than 48 hours, or can't control their coughs or secretions are to be fed by healthy caregivers who encourage breast-feeding and help the mothers express milk, according to the new guidance.

The CDC urges mothers to continue precautions, including hand and respiratory hygiene and wearing a face mask, for at least 7 days after symptom onset and until they have been symptom-free for 24 hours. The new guidance also covers treatment of newborns who have clinical signs of infection as well as discharge planning for mothers and their babies.

During today's conference call, several participants had questions about pandemic flu and breast-feeding. The CDC's subject matter experts said expressed breast milk from sick mothers is safe for babies, even if the mother is on antiviral treatment, and is not thought to contain the virus. However, they noted that the healthcare team should ensure that the breast-feeding equipment is kept clean.

Some participants had questions about respiratory protection for healthcare workers. The CDC experts said surgical N-95 respirators are recommended for staff who could be exposed to splashes during labor and delivery. However, if supplies of surgical N-95s are scarce, workers can wear a plastic face shield over a standard N-95.

CDC experts also fielded some questions about vaccines, clarifying that all versions are compatible with breast-feeding and that there are no contraindications to the mother or other family members getting the live attenuated intranasal form of the pandemic H1N1 vaccine after the baby is born. Because babies younger than 6 months old can't receive the pandemic vaccine, the CDC recommends that their caregivers receive priority vaccination.

See also:

Sep 29 CIDRAP News story "CDC looks to improve H1N1 obstetric guidance"

Nov 10 CDC interim pandemic H1N1 guidance for hospital labor and delivery settings

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