Post-natal follow-up for women and neonates during the COVID-19 pandemic: French National Authority for Health recommendations

Since January 2020 Elsevier has created a COVID-19 resource centre with

free information in English and Mandarin on the novel coronavirus

COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the

company's public news and information website.

Elsevier hereby grants permission to make all its COVID-19-related

research that is available on the COVID-19 resource centre - including this

research content - immediately available in PubMed Central and other

publicly funded repositories, such as the WHO COVID database with rights

for unrestricted research re-use and analyses in any form or by any means

with acknowledgement of the original source. These permissions are

granted for free by Elsevier for as long as the COVID-19 resource centre

Guidelines

Post-natal

follow-up

for

women

and

neonates

during

the

COVID-19

pandemic:

French

National

Authority

for

Health

recommendations

ARTICLE INFO

Articlehistory:

Availableonline11May2020

ABSTRACT

Introduction:Inthecontextofthestage3SARS-Cov-2epidemicsituation,itisnecessarytoputforwarda

methodofrapidresponseforanHASpositionstatementinordertoanswertotherequestsfromthe

French Ministry of Solidarity and Health, healthcare professionals and/or health system users’

associations,concerningpost-natalfollow-upforwomenandneonatesduringtheCOVID-19pandemic.

Methods: A simplified 7-step process that favours HAS collaboration with experts (healthcare

professionals, healthsystemusers’associations,scientific societiesetc.),therestrictiveselection of

availableevidenceandtheuseofdigitalmeansofcommunication.Ashortandspecificdissemination

format,whichcanbequicklyupdatedinviewofthechangesinavailabledatahasbeenchosen.

©2020ElsevierMassonSAS.Allrightsreserved.

Introduction

On14thMarch2020,Franceenteredstage3oftheCOVID-19 epidemicoutbreak.Inaletterdated27thMarch2020,theFrench DirectionGénéraledelaSanté(DGS) referredthemattertothe FrenchNationalAuthorityfor Health (HauteAutorité deSanté; HAS), with a view to drawing up general recommendations designedtoensurecontinuityofcareforpregnantwomenduring lockdown and travel restrictions. Given the very limited data available, theFrenchHighCouncil for PublicHealth considered pregnantwomeninthethirdtrimesterofpregnancytobeatriskof developingasevereformofCOVID-19[1].Rarecasesofvertical transmissionofthevirushavebeenidentified(eventhoughno placentalviremia,orpresenceofthevirusinamnioticfluidorin cordblood hasbeenpublishedtodate) [2–5]. Theextensionof lockdownandtheroleandworkloadofhealthcareprofessionals, leadtore-interviewingorganizationsforthefollow-upofpregnant womenin termsof preventionand care.Theserapid responses focusontheconditionsandorganization ofthereturn homeof mothersandtheirchildrenduringthelockdownperiodandthe managementofcasesofwomenwithCOVID-19(withoutsignsof severity) and their newborns returning home. They should be adapted according to the geographical particularities of the epidemic outbreak and access to local resources. These rapid responsesarebased ontheknowledge availableat thetime of publicationandaresubjecttochangeasnewinformationbecomes available.

Methods

Inthecontextofthestage3SARS-Cov-2epidemicsituation,itis necessarytoputforwardamethodofrapidresponseforaHAS positionstatementinordertoanswertotherequests fromthe

FrenchMinistryofSolidarityandHealth,healthcareprofessionals and/orhealthsystemusers’associations.

A simplified 7-step process that favours HAS collaboration with experts (healthcare professionals, health system users_’ associations,scientificsocietiesetc.),therestrictiveselectionof availableevidenceandtheuseofdigitalmeansof communica-tion. A short andspecificdissemination format, which can be quickly updatedinview ofchanges inavailable data hasbeen chosen.

Step 1) Selection of requests and identification of issues requiringarapidresponsebythePresidentoftheHASCollege.

Step2)DataselectionandanalysisbytheHASteamsinclose collaborationwith experts named by the National Professional Councils (ConseilsNationaux Professionnels - CNP) and French scientificsocieties.Dataselectionhasbeenrestrictedtothebest levelsofevidenceandindescendingorder:

 High Council for Public Health recommendations and French healthagencies

 RecommendationsofFrenchandInternationalscientific socie-ties

 WHOguidelines

 Recommendations from international health agencies (NICE, INESS,etc.)

 Literaturereviewsandrecent2019and2020scientificliterature withrapidcriticalanalysis

Step 3) Drafting of provisional rapid responses by a select working group: HAS team, previously appointed experts and patientassociations

Step4)Reviewandconsultation/informationofstakeholders. Thisstepincludesapanelofdesignatedhealthcareprofessionalsas wellasrepresentativesoftheFrenchinstitutions(FrenchGeneral

http://dx.doi.org/10.1016/j.jogoh.2020.101805

2468-7847/©2020ElsevierMassonSAS.Allrightsreserved.

Available

online

at

ScienceDirect

HealthDirectorate,HighCouncilforPublicHealth).Thesereviews arecarriedoutelectronicallyandallowaresponsewithinashort timeframe.

Step5)Finalizationof therapidresponsesbythepreviously appointedworkinggroup.

Step6)Validationanddisseminationoftherapidresponsesby theHAS. Thetextsarethenpublishedina shortformatonthe websiteoftheHAS,scientificsocietiesandassociationsinvolved. A warningis includedin thetext:"Theserecommendations, drawnuponthebasisoftheknowledgeavailableatthedateof theirpublication,aresubjecttochangeandarelikelytobeupdated inlightofnewavailabledata_”.

The experts' ties of interestare analysed by theHAS ethics officerandthelegaldepartment,onthebasisoftheinformation available in the "DPI-HEALTH and TRANSPARENCY-HEALTH" databases,andareprovidedtothemembersoftheHASCollege fortheirinformation

Step 7) Regular update of the rapid responses taking into account the developments in the scientific literature and the recommendationsfromscientificsocieties.

ThisdocumentwasdrawnupjointlybytheHASandexperts appointed by the Collège National des Gynécologues et Obstétriciens Français (CNGOF), the Collège National des Sages-femmes de France (CNSF), the Collège de la Médecine Générale(CMG),the Société Françaisede Néonatalogie (SFN), theSociétéfrançaisedepédiatrie(SFP),theFédérationFrançaise desRéseauxde SantéenPérinatalité (FFRSP),theAssociation FrançaisedePédiatrieAmbulatoire(AFPA).Therapidresponses were reviewed by the Collectif Interassociatif Autour de la Naissance(CIANE).

Recommendations

Dischargeafterchildbirth:conditionsandorganizationofthereturn homeofmothersandtheirnewbornsduringtheCOVID-19pandemic

AsthehospitalisconsideredaCOVID-19cluster,earlydischarge formothersandchildrenatlowmedical,psychologicalandsocial riskisrecommended(Table1):

Whenpossible,within48hofthenewborn’slifeforawoman givingbirthbyvaginaldelivery[6].

Ifdischargefromthematernitywardisplannedbefore48hof life,theHASrecommendationsapply,withregardtothecriteriafor reinforcedsurveillanceof thenewbornand theorganization of neonatalscreening.

Whenpossible,within96hofthenewborn'slifeforawoman givingbirthbycaesareansection.

Before any early discharge from the maternity ward, the newbornisexaminedbyapaediatricianaccordingtothesituations mentionedabove:before48h,at48hoflifeandafter96h.  It is advisable that a post-natalcare consultant accompanies

women,particularly thoseinprecarioussituationsorthosein vulnerablepsychologicalorsocialsituations,inorderto:  Carryout screening,prevent complicationsand identifythem

early in order to refer the patient to another professional if necessary

 Identifyaneedforfollow-uporadditionalassistanceorreferral viatheappropriatechannels.

Anticipatepossibleinfectionofthenewborntoorganizereturnhome  NewbornsofaCOVID+mothershouldbeconsideredcarriersofthe

virus.

 Routine screening of newborns of COVID- or non COVID+ sus-pectedmothersisnotcurrentlyrecommended.

The American Academy of Pediatrics (AAP) and Society of Obstetricians and Gynecologists (SOGC) recommend that new-bornsofaCOVID+motherbeconsideredsuspectforCOVID-19.The authorssuggestthatthevalueofascreeningtestistoorganize postpartumcareandtoprovideclosemonitoringofthenewborn [7,8].IntheFrenchcontext,theHASconsidersitmoreprudentto consideranynewbornofaCOVID+motherasacarrierofthevirus. Testingthenewbornisthereforenotjustified.Theprecautionsto betakenaretostayconfinedathomewiththechild,toavoidtoo closecontactwithfamilymembers(especiallysiblingsandpeople atrisk),towearasurgicalmaskandtohavestricthandhygiene. Temperatureandappearanceofsymptomsofrespiratoryinfection shouldbemonitoredinbothmotherandchild.

A systematic review of 23 studies(20 Chinese,1 Korean,1 American,and1fromHonduras)evaluatedthatofatotalof122 infantstestedoutof162infantsborntomotherswithCOVID-19, 10%werefoundtobepositiveforSARS-CoV-2byRT-PCR(withone stillbornandoneperinatallydeceasedchildwithnospecifiedlink toCOVID-19)[9].TheFrenchSocietyofNeonatology(SFN)stresses that the results of a test would not influence maternity unit practices (no separation of mother and child and possible breastfeeding)ortheimplementationofprotectionand surveil-lancemeasuresintheeventofaninfectedmotherorchild(while nevertheless protecting the other children in the household). Indeed,sincethebeginningoftheCOVID-19epidemicoutbreak, children, especially newborns, are a more protected group, as evidenced by the low proportion of children among the total number of infected persons(between 1 and 5%)and the more benignnatureoftheirinfection[10].

Table1

Post-natalfollow-upforwomenandneonatesduringCOVID-19pandemic:HASrecommendations.

RapidResponse#1:RarecasesofverticaltransmissionofSARS-CoV-2havebeenidentifiedandthereisnoevidenceoftransmissionduringbreastfeeding.Afterbirth,the newbornislikelytobeinfected.LockdownandbarriermeasuresmustbefollowedandreinforcedifthemotherisinfectedwithCOVID-19.

RapidResponse#2:Encourageearlydischarge,fromthe48th

houroflifeofthenewborn,bypromotingcommunicationandtown/hospitalorganization. RapidResponse#3:Haveaphysicalexaminationofthenewbornbetweenthe6th

and10th

dayafterbirthcarriedoutbyapaediatricianorageneralpractitionerwithin theframeworkofanorganizedcaresystem.

RapidResponse#4:Proposefollow-upbyremoteconsultationorface-to-facebasedontheassessmentoftheclinicalsituation,butalsoonthewoman'ssocialand psychologicalcontext.

RapidResponse#5:Ensurethephysicalandmentalwell-beingofthemother,maintainpsychologicalsupportforwomen,includingremotely,andaccompanythe motherorcoupleintheirparentingpractices

RapidResponse#6:Reinforcefollow-upincaseofveryearlydischarge(before48hoflife)

RapidResponse#7:Payparticularattentiontothejaundiceriskmonitoringcircuitandfollow-upinthematernitywardincaseofconfirmedjaundice

RapidResponse#8:Modulateorganizationofpostnatalmonitoringaccordingtothegeographicalparticularitiesoftheepidemicoutbreakandaccesstolocalresources 2 A.J.Vivantietal./JGynecolObstetHumReprod49(2020)101805

Currentdata,feedbackfromprofessionalsinthefieldonthe impactofcarryingoutscreeningtestsonmaternitypractices,the conditions ofreturn homeand findings onchild health do not makeitpossibletosystematicallyrecommendascreeningtestfor children. If the mother’s COVID status is known, that of the newbornmustinfactbeconsideredtobeidentical.Incaseofthe slightestsymptom,bothmotherandchildshouldbetested. Adapttheconditionsandorganizationofpostnatalfollow-upathome formothersandtheirnewborns

Theconditionsandorganizationofthereturnhomefollowthe HAS recommendations while adapting to the context of the epidemic[6].

Afirstroutinevisitiscarriedoutbyamidwifeideallywithin24h afterleavingthematernityunit.Themotherleavesthematernity unitwiththisappointment.

Asecondvisitcanbescheduledifdecidedbythemidwife,by remoteconsultationorface-to-facedependingonthesituation. If necessary, she will contact the obstetrician and/or the paediatricianand/orthegeneralpractitioner.

Othervisitscanbeplannedaccordingtothemedicalaspectsto bemonitored,themother’svulnerabilitiesorsocialor psycho-logicalcontext,and/orifthemotherorthecouplefeeltheyneed them;theycanbecarriedoutbyremoteconsultation.

Forat-risk women,ifhospitalizationat homeis indicated,it shouldbepreferreddependingontheresourcesavailablelocally [11].

Thefirsthealthcertificate"tobedrawnupwithinthefirsteight daysoflife"issystematicallyissuedbyadoctor(paediatricianor generalpractitioner).Itcanbefilledinwhenleavingthematernity unit.

Given theshorter length of stay in thematernity unit, it is recommended that a newborn child be examined in person betweenthe 6th and 10th dayafter the birth, preferablyby a paediatricianorageneralpractitioner.

The newborn’svisit planned duringthe second week(close medicalsupervision oftheinfant)is left,duringanoutbreakof COVID-19, to the decision of the paediatrician or general practitionerwhoexaminedthechildbetweenthe6thand 10th daypostpartum.

Maternalmonitoringparameters

Bleeding, infectious,thromboembolic, urinary,digestive, scar-ringandpainrisk

 Signsofphysicalandpsychologicaldistress(quantityandquality ofsleep,stateoffatigue,mood);postpartumdepression(which can occur within two weeks of birth or later), especially in womenwhohaveshownsignsofdepression sincepregnancy and/orexpressexcessiveconcernabouttheirmaternalcapacity [11];situationofdomesticviolenceinthecontextoflockdown [12].Psychologicalsupportmaybenecessary.

 Breastfeedingdifficulties,adaptedresponsetonewborncrying.  Risk of child abuse, especially Shaken Baby Syndrome: the quality of support fromfamily and friends is essential, as is recoursetopsychologicalsupport[13].

 Inacontextoflockdownandfamilyisolation,itisessentialto reinforcepostnatalmonitoringbyremoteconsultation, particu-larlyformonitoringbreastfeeding[14],screeningforpostnatal depression, and support for the mother or couple in their parenting practices (especially for first time mothers): two postnatalremoteconsultationscanbeconductedbyamidwife betweenthe8thdayafterdeliveryandthepostnatalvisit.  The postnatal visit is maintained at the hospital/practice six

weeks after delivery:gynaecological examination, method of contraception, vaccinations, screening smears, pelvic floor physiotherapy, experienceof childbirthand the aftermath of childbirth, assessment of signs of distress or depression, relationshipwiththechildandwithinthecouple.

 Pelvicfloor physiotherapysessions,usually started six weeks afterdelivery,canbearrangedremotely.

Childmonitoringparameters

 Riskofjaundice(focusonTable2)

 Riskof heart disease: if there is any doubt asto thecardiac auscultation,orifthefemoralpulsesarenotperceivedorthere areanyothersignsofheartfailure,aspecialtelephonehelpline mustbesetuptoreachthematernitywardpaediatrician,witha linethroughtothepaediatriccardiologydepartment.

 Risk of dehydration/undernutrition: weight, monitoring of effective feeding (well established breastfeeding or artificial breastfeeding):urineoutputateachnappychange,spontaneous andregularbowelfunction(threetofourstools/day).

 Infectious risk (COVID-19 and others): temperature(hypo or hyperthermia),respiratoryrate,hemodynamicdisorders(longer capillaryrefilltime),diarrhoea.

Reinforcesurveillanceincaseofveryearlydischarge,before48h  Thiscan only be possibleif local resourcesand organization

permitit,includingtheorganizationofneonatalscreeningtests

Table2

:Focusonhowtoorganizedischargeforjaundiceandthepreventionofseverehyperbilirubinemia.

Thejaundiceriskassessmentmustbeintegratedintothereasoningleadinguptothedecisionfordischargefromthematernityunit.

Foreachchild,compilationofajaundiceprofilebasedonthenormogram[23],combinedwiththerecognitionofriskfactorsforseverehyperbilirubinemia,ensuresthat thechildisdischargedinoptimalsafetyconditionsandthusreducestheriskofreadmissiontohospitalforhyperbilirubinemia.

Jaundicefollow-upproceduresshould:

beeffectivewithin24hofearlydischargefromthematernityunit. enablequantificationofjaundice.

enablephysicalevaluationofthechild(weighing)andbreastfeeding(observationofafeed). identifyapossiblereturnroute(ifnecessary)toacarefacility.

Parentsmustbeinformedofthewarningsignsandofwhotocontactintheeventofanemergencypriortodischarge[24].

Itisrecommendedthatjaundicedataberecordedinthechild'shealthrecord,orthatthisinformation(riskfactors,profileoutcome,diagnosisandtestresults)be mentionedontheimmediatepost-partumliaisonsheetfortheprofessional(s)providingfollow-up[6].

Inpractice,ifthemidwifedoesnothaveabilirubinometer,sheshouldbeabletoarrangeforabilirubintestatthematernityward.Aspartofearlydischargeduringthe COVID-19pandemic,itisimportanttomonitorclinicalsignsandarrangeforbilirubinmonitoringataprivatepracticeoratthehospitalifnecessary.

andtimelycompletionof thosetests.Screeningformetabolic diseasesmustbecarriedoutbetween48and72hoflifewith transmissionofblotterswithin24htoguaranteereliability[15]. Communicationandtown/hospitalorganizationisessentialfor

theappropriatecareofthemotherandchild.

Earlyexaminationof thenewbornbythepaediatricianinthe maternity ward before discharge in the same way as for discharge at 48hhas tobe considered, as well as early and rapid follow-up by the midwife at home. Monitoring by bilirubinometershouldtake placeafter 24haccordingtothe localorganization.

Pointsofcautionregardingneonatalscreeningtests

The results of neonatal screening tests should be routinely recordedinthechild'shealthrecord.

Systematicneonatalscreeningformetabolicdiseases:Inviewof thelockdownmeasurestakenbythepostoffice,whichhavean impact on the delivery of "blotting paper" tests to neonatal screeningreferencecentres,dischargefromthematernityward after48hwillensurethatneonatalscreeningcanbecarriedout ingoodconditions.

Hearingscreening:Ifhearingscreeningcouldnotbecarriedout inthematernityward(attheearliestafter24h)orifacheck-up is necessary, schedule this screening or obtain diagnostic confirmationoncetheepidemicsituationhaspassed.

Screeningforcriticalcongenitalcardiopathies:measurementof rightupperlimbandlowerlimbsaturationbetween6hand24h beforeleavingthematernityhospital:definitionoftheactionto be taken in liaison with the referring maternity hospital paediatriccardiologist.

Screening for congenital hip dislocation: repeated physical examinationateachroutinenewbornandinfantvisit.In case ofabnormalphysicalexamination(abductionlimitation, insta-bility),anultrasoundshouldbeperformedandtreatmentshould be implemented further to orthopaedic assessment. If risk factorsarepresent,ahipultrasoundshouldbeperformedbefore theageof3months.

Supportforambulatorycare

Theimplementationoftheserapidresponsesimpliesessential supportforthecareoffer,whichiscurrentlybelowstandardinthe context of the COVID-19 epidemic (closure of some day care structures, few personal protection measures in terms of equipment for midwives, less post-natal home follow-up by midwives).Thedaycarestructures(Maternalandchildwelfarein Franceis the name of the protection system for mothers and children)haveanimportantroletoplayinthecontinuityofcare andmustparticipateinthefollow-upofwomenandtheirchildren (doctor,home-visitingnurserynurse)byrestrictingtheiractivities, whilefollowingbarriermeasures.Theorganizationof postnatal monitoringshouldbemodulated accordingtothegeographical particularities of the epidemic outbreak and access to local resources,perinatalhealthnetworksplayingamajorrole.

In the context of COVID-19, teamwork, communication and informationsharingmustbestrengthenedbetweenthehospital and town to increase efficiency and safety. The methods are determined jointly by the healthcare professionals involved in caringforwomen(midwives,obstetricians,paediatricians,general practitioners,etc.).Giventhemidwives’roleoutsidethehospitalin monitoringwomenandtheirchildrenafterbirth,itisessentialto ensure they have all the appropriate personal protective

equipment theyneed(masks,overalls, gloves,etc.).Institutions must drawup a listofmidwivesoutside thehospital who can providefollow-upcareforwomenandtheirchildrenafterbirthto reinforcethetown/hospitallink.Theroleofperinatalnetworksis essentialintheepidemiccontext.Allofthesemeasuresaimtostep upambulatorycareandfacilitatethemanagementofpatientswith COVID-19byobstetricalteamsinhealthfacilities.Ambulatorycare isdefinedasmedicalcarecarriedoutbyanyhealthnon-hospital personnel (midwife, general practitioner and gynaecologist-obstetrician)whoworkinthecity.

WomenandtheirnewbornsreturninghomewithCOVID-19(without signsofseverity)

The general practitioner and all home-visiting healthcare professionalsmustbeinformedofthemother'sinfection.

NewbornswithoutcomorbiditiescanstaywiththeirCOVID-19 +motherandbebreastfed(unlessthemotheraskstobeseparated fromherchild).

The FrenchSociety of Neonatology(SFN) and the Paediatric Infectious PathologyGroup(GPIP)donot currentlyrecommend separation of mother and child and do not contraindicate breastfeeding[10].

Motherandchildmonitoringparameters

AmotherwithCOVID-19andherchildaremonitoredbytheir general practitioner and, if necessary, the paediatrician for the newborn.

Atthesametime,themidwifecanensurepostnatalsupervision ofthemotherandthechildinliaisonwiththereferringobstetrical team.

Any woman or child with signs of severe COVID-19 or aggravatingcomorbiditiesshouldbetakentoahealthcarefacility. Monitoringandfollow-upforaCOVID-19+mother

 Activemonitoringofhertemperatureandonsetofsymptomsof respiratoryinfection(fever,cough,breathingdifficulty,sensation ofsuffocationetc.).

 Strictlockdownwiththechild.

 Tooclosecontactwithfamilymembersshouldbeavoided.  Amask(surgicalmask)shouldbeworn.

 Stricthandhygiene:handsshouldbewashedbeforetakingcare ofthechild.

 Thegeneralpractitionerorthenurseshouldcontactthemother every24htofollow-upontheinfection(tracingtheresultstobe recoveredandcallsmade),givingprioritytoremoteconsultation orremotecarewhenpossible.

 Postnatalmonitoring of mother and child by the midwifein liaisonwiththereferringobstetricalteam.

 Exitfromisolationafterrecoveryasinthegeneralpopulation. [15]

 Consultationwithadoctorthreeweeksafterdischarge. Monitoringandprecautionsforinfantsborntomotherswith COVID-19

 Activemonitoringoftemperatureandtheonsetofsymptomsof respiratoryinfection(fever,cough,breathingdifficulties,etc.), diarrhoea.

 Strictlockdownwiththemother.

 Itisnotrecommendedfornewbornstowearmasks

 First consultation within 24h of arrival at home with the midwife,then a consultation betweenthe 6th and 10th day postpartum, preferably at the paediatrician’s or general

practitioner'spractice,inaccordancewiththesafetyprotocolin place (for example at the end of a consultation with a paediatricianataspecialclinicfornewbornsorsmallinfants). Although compulsory, in the event of a COVID-19 epidemic, examinationofthenewbornplannedduringthesecondweek (close medical supervision of the infant) is decided by the paediatrician or general practitionerwho examined thechild betweenthe6thand10thpostpartum.

Anysymptomsinthenewbornshouldbereportedtothehealth careprofessionalwholooksafterthechildandshouldgiveriseto aconsultation,anddeterminethefrequencyoffollow-up. In caseofemergency:gotothepaediatric emergency

depart-mentofthereferencehospitalhavingfirstcalledtheemergency services.

Nodataareavailableontheimpactofearlymaternalinfection duringpregnancyonchilddevelopment:closemonitoringofthe childateachvisit[16,17].

Lockdownathome

AswithanypersonconfirmedtobeCOVID-19+,self-isolationat home for 14 days after the onset of the first symptoms is recommended and special precautions should be taken. The precautionsapplicabletowomenwithCOVID-19arethesameas for thegeneral population(barrier measures, social distancing, lockdown) to reduce the risk of transmission. Specific recom-mendationsalsoapply.

Monitoring instructions and hygiene precautions to be ob-servedmustbegivenandexplainedtothewomanorcouplebefore leavingthematernityunit.

Motherandchildorganizationathomeafterleavingthematernity unit

At home, the mother is advised to isolate with the child, if possible,in a separate room,avoidingcontact withthe other occupants,andtoairtheroomregularly.Ahotelroomisavailable ifthemotherprefers (COVISANsystemin Paris,orequivalent elsewhere).

Thecotshouldbeplacedaboutsixfeetfromthemother'sbedor chair.

Alloccupantsshouldwashtheirhandsfrequentlyafterusingthe bathroom and toilet, which must be cleaned regularly with bleachordisinfectant.

Surfacestouchedregularly(doorhandles,mobilephones,etc.) arecleaneddailyanddisinfected).

Itisnotadvisabletoreceivevisitsunlesstheyareessential,such asvisitsfromamidwife,nurse,childcareworkerorhomehelp.

Breastfeeding

Studiesshowthattheviralgenomeisnotfoundinthebreast milk of COVID-19-infected mothers [3,18–20]. Breastfeeding therefore does not appear to be contraindicated [21,22]. A COVID-19+mother,orsuspectedtohaveCOVID,andsymptomatic, shouldtakeallthenecessaryprecautionstoavoidtransmittingthe virustoherinfant.Sheshouldwashherhandsbeforetouchingthe infant,wearafacemask,andifpossible,duringbreastfeeding.If themotheris expressing milkwitha manualor electricbreast pump,orfeedsherchildwithbabyformula,sheshouldwashher handsbeforetouchinganypartofthebreastpumporbottleand follow the recommendations for proper cleaning of the breast pumporbottleaftereachuse.

Implementprotectivemeasuresduringexaminationandcareofthe newbornchild

During examinationorcareof thenewborn,duringthefirst monthoflife,itisrecommendedtowearamaskandtowashhands beforehand (usingsoaporhad sanitizer)Thenewborn mustbe seen again for the first month visit in person. Mandatory vaccinationsmustbeadministeredattwomonthsoflife(possible from6weeks).

Acknowledgments

WewouldliketoextendourthankstoMrsMadeleineAkrich, France Artzner, Anne Evrard from the Collectif Interassociatif AutourdelaNaissance(CIANE)whoreadtherecommendations. DeclarationofCompetingInterest

Theauthorsdeclarenocompetinginterests

References

[1]HautConseildeSantéPublique.Avisdu31mars2020relatifàlapréventionet àlapriseenchargedespatientsàrisquedeformesgravesdeCOVID-19ainsi qu’àlapriorisationdestestsdiagnostiques[Internet].2020Availablefrom:

https://www.hcsp.fr/explore.cgi/avisrapportsdomaine?clefr=790.

[2]ChenL,LiQ,ZhengD,JiangH,WeiY,ZouL,etal.Clinicalcharacteristicsof pregnantwomenwithCovid-19inWuhan.China.nengljmed.2020;3:. [3]ChenH,GuoJ,WangC,LuoF,YuX,ZhangW,etal.Clinicalcharacteristicsand

intrauterineverticaltransmissionpotentialofCOVID-19infectioninnine pregnantwomen:aretrospectivereviewofmedicalrecords.Lancet2020;395 (10226)809–15Mar7.

[4]DongL,TianJ,HeS,ZhuC,WangJ,LiuC,etal.PossibleVerticalTransmissionof SARS-CoV-2FromanInfectedMothertoHerNewborn.JAMA[Internet]2020 Mar26[cited2020Apr13];Availablefrom:https://jamanetwork.com/ journals/jama/fullarticle/2763853.

[5]YuN,LiW,KangQ,XiongZ,WangS,LinX,etal.Clinicalfeaturesandobstetric andneonataloutcomesofpregnantpatientswithCOVID-19inWuhan,China: aretrospective,single-centre,descriptivestudy.LancetInfectDis2020Mar24. [6]HauteAutoritédeSanté.Sortiedematernitéaprèsaccouchement:conditions

etorganisationduretouràdomiciledesmèresetdeleursnouveau-nés [Internet].2014Availablefrom:https://www.has-sante.fr/upload/docs/

application/pdf/2014-03/recommandations_-_sortie_de_maternite_apres_accouchement.pdf.

[7]Puopolo KarenM,HudakMarkL, KimberlinDavidW, CummingsJames. AmericanAcademyofPediatrics.Managementofinfantsborntomotherswith COVID-19[Internet].2020Availablefrom:https://downloads.aap.org/AAP/ PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf.

[8]ElwoodChelsea, BoucoiranIsabelle,VanSchalkwykJulie,MoneyDeborah, YudinMark,PoliquinVanessa.Covid19pendantlagrossesse[Internet].2020 Availablefrom:https://www.sogc.org/fr/content/featured-news/D%c3% a9claration-de-la-SOGC%e2%80%93COVID-19.aspx.

[9]GajbhiyeR,ModiD,MahaleS.Pregnancyoutcomes,newborncomplications andMaternal-FetalTransmissionofSARS-CoV-2inwomenwithCOVID-19:a systematicreview[Internet].ObstetricsandGynecology2020,doi:http://dx. doi.org/10.1101/2020.04.11.20062356Apr[Cited2020Apr25].Availablefrom:. [10]Société française de Néonatalogie. Société française de Pédiatrie.

Propositionsdelasociétéfrançaisedenéonatalogieetdelasociété françaisedepédiatrieconcernantlesnouveau-nésdanslecontexte d’épidémieàcovid-19[Internet].2020Availablefrom:http://www.co-naitre. net/wp-content/uploads/2020/03/RECO-SFN-SFP-COVID-19.pdf.

[11]Haute Autorité de Santé. Situations pathologiques pouvant relever de l’hospitalisationàdomicileaucoursdel’anteetdupost-partum[Internet]. 2011Availablefrom: https://www.has-sante.fr/jcms/c_1066375/fr/situations- pathologiques-pouvant-relever-de-l-hospitalisation-a-domicile-au-cours-de-l-ante-et-du-post-partum.

[12]HauteAutoritédeSanté.Repéragedesfemmesvictimesdeviolencesausein ducoupleSaint-Denis[Internet].2019Availablefrom:https://www.has-sante. fr/jcms/p_3104867/fr/reperage-des-femmes-victimes-de-violences-au-sein-du-couple.

[13]HauteAutoritédeSanté.Syndromedubébésecouéoutraumatismecrânien nonaccidentelparsecouement.Actualisationdesrecom-mandationsdela commissiond’auditionde2011[Internet].2017Availablefrom:https://www. has-sante.fr/jcms/c_2794425/fr/syndrome-du-bebe-secoue-ou-traumatisme-cranien-non-accidentel-par-secouement.

[14]SantépubliqueFrance.Leguidedel’allaitementmaternel[Internet].2018 Availablefrom:https://www.santepubliquefrance.fr/determinants-de-sante/ nutrition-et-activite-physique/documents/brochure/le-guide-de-l-allaitement-maternel.

[15]HauteAutoritédeSanté.Sortiedematernitéaprèsaccouchement:conditions etorganisationduretouràdomiciledesmèresetdeleursnouveau-nés [Internet].2020Availablefrom:https://www.has-sante.fr/upload/docs/

application/pdf/2014-03/recommandations_-_sortie_de_maternite_apres_accouchement.pdf.

[16]American College of Obstetricians and Gynecologists. Covid-19Obstetric preparednessmanual.[Internet].2020Availablefrom:https://www.acog. org/-/media/project/acog/acogorg/files/pdfs/education/covid-19-obstetric-preparedness-manual.pdf.

[17]ZaighamM,AnderssonO.MaternalandPerinatalOutcomeswithCOVID-19:a systematicreviewof108pregnancies.ActaObstetriciaetGynecologica Scandinavica[Internet]2020,doi:http://dx.doi.org/10.1111/aogs.13867[cited 2020Apr12];n/a(n/a).Availablefrom:.

[18]RasmussenSA,SmulianJC,LednickyJA,WenTS,JamiesonDJ.Coronavirus Disease2019(COVID-19)andpregnancy:whatobstetriciansneedtoknow.Am JObstetGynecol.2020Feb24.

[19]WangS-S,ZhouX,LinX-G,LiuY-Y,WuJ-L,SharifuLM,etal.Experienceof clinicalmanagementforpregnantwomenandnewbornswithnovel coronaviruspneumoniainTongjiHospital.China.CurrMedSci.2020Mar26. [20]CentersforDiseaseControlandPrevention.Pregnancyandbreastfeeding. InformationaboutCoronavirusDisease2019[Internet].2020Availablefrom: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/ pregnancy-breastfeeding.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc. gov%2Fcoronavirus%2F2019-ncov%2Fprepare%2Fpregnancy-breastfeeding. html.

[21]DavanzoR,MoroG,SandriF,AgostiM,MorettiC,MoscaF.Breastfeedingand CoronavirusDisease-2019.AdinterimindicationsoftheItalianSocietyof NeonatologyendorsedbytheUnionofEuropeanNeonatal&Perinatal Societies.MaternChildNutr2020e13010n/a(n/a).

[22]World Health Organization Réginal Office for Europe. COVID-19 and breastfeeding.Positionpaper[Internet].2020Availablefrom:http://www. euro.who.int/__data/assets/pdf_file/0010/437788/breastfeeding-COVID-19. pdf?ua=1.

[23]HyperbilirubinemiaS.ManagementofHyperbilirubinemiainthenewborn infant35ormoreweeksofgestation.Pediatrics2004;114(1)297–316Jul1. [24]françaisedeNéonatalogieSociété.SociétéfrançaisedeNéonatologie.Jaunisse

ouictèredunouveau-né.Laphotothérapie.Informationsdespatients [Internet].2015Availablefrom:http://www.cnrhp.fr/docs/

PLAQ_PARENTS_2015.pdf. AlexandreJ.Vivantia,* PhilippeDeruelleb,i OlivierPiconeb,j SophieGuillaumec Jean-ChristopheRozed BlandineMuline FabienneKochertf IsabelleDeBecog SophieMahutg AdrienGantoisc ChloéBarasinskic,k KarinePetitprezh Anne-FrançoisePauchet-Traversath AlcyoneDroyh AlexandraBenachia,b

a_{ServicedeGynécologieObstétrique,HôpitalAntoineBéclère,AP-HP,}

UniversitéParis-Saclay,Clamart,France

b_{CollègeNationaldesGynécologuesObstétriciensFrançais,France} c_{CollègeNationaldesSages-FemmesdeFrance,France} d_{ConseilNationaldesProfessionnelsdePédiatrie,France} e_{FrenchFederationofPerinatalHealthNetworks,France} f_{FrenchAssociationofAmbulatoryPaediatrics,France} g_{CollegeofGeneralMedicine,France} h_{GuidelinesDepartment,FrenchNationalAuthorityforHealth,}

Saint-Denis,France

i_{ServicedeGynécologie-Obstétrique,HôpitaldeHautepierre,Faculté}

deMédecinedeStrasbourg,Strasbourg,France

j_{DivisionofObstetricsandGynecology,“LouisMourier”Hospital,}

ParisUniversity,IAMEINSERMU1137,APHPParis,France;Groupede RecherchesurlesInfectionspendantlaGrossesse

k_{UniversitéClermontAuvergne,CNRS,CHUClermont-Ferrand,}

SIGMA,INSTITUTPASCAL,F-63000Clermont-Ferrand,France * Correspondingauthorat:ServicedeGynécologie-Obstétrique, HôpitalA.Be’clère,GHUParisSaclay,APHP,157ruedelaPortede Trivaux,92140ClamartFrance E-mailaddress:alexandre.vivanti@aphp.fr(A.Vivanti).