Care of a Neonate Born to a Patient with Confirmed or Suspected Ebola Disease

What is Known About Neonates Born to Patients with Ebola Disease?

While data are limited, reports from past Ebola disease outbreaks indicate that spontaneous fetal loss is high among patients that become infected during pregnancy^2-4. Neonates born to patients with Ebola disease are often premature, and typically do not survive for more than a few weeks^2,5,6,7, with one published exception¹⁹. It is not clear whether these deaths are due to in utero transmission of ebolavirus to the neonate or to other factors that contribute to high infant mortality rates in countries affected by Ebola disease.⁷ However, data suggests there is in utero ebolavirus transmission to the fetus.⁴ Further, there are limited data on clinical signs at presentation of Ebola disease in neonates. In a 1976 outbreak, among 11 neonates born to patients with Ebola virus disease due to infection with Ebola virus (species Zaire ebolavirus), seven had fever with few other signs or symptoms⁷. There is no experience with neonates born to patients with Ebola disease in settings with a highly developed healthcare system.

The first published report of neonatal survival in an infant born to a patient infected with Ebola virus occurred in 2015. This infant was born to a 25-year-old previously healthy woman who reported onset of symptoms eight days prior to delivery. The patient was treated with favipiravir on day 5 of her illness and died on the eighth day of her illness (hospital day 5) due to severe vaginal bleeding after a spontaneous vaginal delivery. Her infant was treated with monoclonal antibodies (ZMapp), a buffy coat transfusion from an Ebola virus disease survivor, and the antiviral GS-5734. Aside from seizure-like activity, the infant had no other symptoms and was discharged home. Subsequent weekly follow-up demonstrated normal development and growth at 12 months of life.¹⁸

In 2020, a case series was published describing survival in two neonates born to patients infected with Ebola virus who died shortly after childbirth. Both the patient and neonate pairs received Ebola virus-specific monoclonal antibody treatment (Inmazeb, Ebanga)²⁰. Inmazeb and Ebanga are now both FDA-approved therapies for the treatment of Ebola virus disease due to Ebola virus in adult and pediatric patients, including neonates born to a patient who is RT-PCR positive for Ebola virus infection.²¹

The following guidance is based on the current, yet limited, knowledge and best practices for infection control.  As more information is learned about neonates born to patients with Ebola disease, this guidance may change. Additionally, guidance is available from CDC on caring for pregnant patients with Ebola disease in U.S. hospitals.⁸

Care of a Neonate Born to a Patient with Confirmed Ebola Disease

Given the risk of vertical transmission and the high mortality of neonates infected with Ebola virus (species Zaire ebolavirus), post-delivery administration of Inmazeb or Ebanga should be strongly considered for all live-born neonates of Ebola virus-positive patients.

It is not known if, or when, neonates born to patients with Ebola disease acquire ebolavirus infection perinatally. A neonate delivered of a patient with confirmed Ebola disease should be considered a suspect Ebola case. Local public health officials and CDC should be alerted. The neonate should be immediately separated from the patient and cared for in an isolation unit for 21 days. Healthcare workers caring for a neonate born to a patient with confirmed Ebola disease should follow recommendations for use of personal protective equipment (PPE) when caring for patients with Ebola disease.⁹ If resuscitation is indicated, it should occur with adherence to isolation precautions, environmental hygiene, and waste management, as well as worker safety practices that include the use of PPE, and in accordance with the principles of the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program.^9,10

Decisions to discharge the neonate after 21 days of monitoring with no signs of infection and a negative result of ebolavirus testing by RT-PCR on a blood specimen should be made in conjunction with local public health authorities.

Care during isolation

To date, there has been one report of a healthy neonate born to a patient with confirmed Ebola disease.¹⁹ In the circumstance that a neonate born to a patient with confirmed Ebola disease is healthy and stable, routine newborn care should be provided and non-invasive screening tests should be conducted.¹¹ Appropriate PPE should be worn at all times.⁹ Decisions to delay invasive screening tests and immunizations should consider the diagnosis of Ebola disease in the neonate, maternal conditions (such as Hepatitis B), and family history. Circumcision should be delayed until the 21-day isolation period has concluded and/or a negative result for ebolavirus testing by RT-PCR on a blood specimen has been documented to prevent ebolavirus exposure of healthcare workers. Decisions on when circumcision can safely be performed should be made in conjunction with local public health authorities. A careful history should be sought to ensure that the patient was screened for other causes of tropical febrile illnesses that could contribute to increased morbidity in the neonate, especially malaria. If the neonate becomes febrile during hospitalization, local causes of fever, including hospital-acquired bacterial infections and viral illnesses other than Ebola disease, should also be sought.

Breastfeeding Recommendations

Ebola virus (species Zaire ebolavirus) genetic material has been identified in the breast milk of lactating patients.^{13, 14} Since Ebola virus has been shown to be present in breast milk, neonates born to patients with confirmed Ebola disease should not breastfeed. There is not enough evidence to provide guidance on when it is safe to resume breastfeeding after the patient recovers from Ebola disease. Where available, ebolavirus testing of breastmilk can help to guide decisions about when breastfeeding can be safely resumed.

Donor breast milk or Ready to Use Infant Formula (RUIF), if available, may be an acceptable substitute.

Safe Handling of Breast Milk in Healthcare Settings

Standard precautions for prevention of transmission of bloodborne pathogens do not apply to human breast milk in most circumstances.¹⁵ There are no data about the risks from exposure to breast milk containing ebolavirus in healthcare settings; therefore, when a breastfeeding patient has confirmed Ebola disease, PPE guidance should be followed for anyone handling the breast milk.^9,16 The expressed milk of a patient with confirmed Ebola disease is considered Category A infectious waste and must be disposed of in accordance with CDC guidance on waste management.¹⁷

Care of a Neonate Born to a Patient with Suspected Ebola Disease

A neonate born to a patient with suspected Ebola disease should be treated as a suspect Ebola case until the Ebola disease status of the patient is determined. The neonate should be immediately separated from the patient, placed into isolation for 21 days, monitored for ebolavirus infection, and cared for with appropriate PPE.⁹ If the patient is confirmed to have Ebola disease, healthcare workers should follow the guidance above on care of a neonate born to a patient with confirmed Ebola disease. If it is determined that the patient does not have Ebola disease, the neonate may be removed from isolation and cared for using standard hospital protocol. If the patient later develops signs and symptoms consistent with Ebola disease during her 21 days of monitoring, the neonate should be separated immediately, placed into an isolation unit and cared for with appropriate PPE until ebolavirus infection in the neonate is ruled out.⁹ If the patient tests positive for ebolavirus, the 21-day monitoring period would be reset for the neonate to the date of last contact with the patient. Decisions to discharge the neonate after 21 days of monitoring with no signs of infection and a negative ebolavirus test by RT-PCR on a blood specimen should be made in conjunction with local public health authorities.

Care during isolation

A neonate born to a patient with suspected Ebola disease should be cared for using the same guidelines used for a neonate born to a patient with confirmed Ebola disease, until the Ebola disease status of the patient is determined.

Breastfeeding Recommendations

A breastfeeding patient with suspected Ebola disease should not breastfeed until the Ebola disease status is resolved. Donor breast milk, if available, may be an acceptable substitute. To establish and maintain breast milk production, the patient may express breast milk. If pumping, the patient must use a dedicated breast pump that remains in the patient’s room. The breast pump must not be used for any other patient. If the patient is determined to not have Ebola disease, breastfeeding of the neonate can begin. If the patient is confirmed to have Ebola disease, the guidance for a patient with confirmed Ebola disease should be followed.

Safe Handling of Breast Milk

When a breastfeeding patient is under evaluation for ebolavirus infection, PPE guidance should be followed for anyone handling the breast milk.^9,16 The expressed milk of a patient under evaluation for ebolavirus infection is considered Category A infectious waste and must be disposed of in accordance with CDC guidance on waste management.¹⁷

Care of a Neonate Born to an Asymptomatic Person with Potential Exposure to an Ebolavirus

A neonate born to an asymptomatic person with a potential ebolavirus exposure during pregnancy should be placed in the same risk category as the potentially exposed person and monitored following birth. The neonate can remain in the same room as the potentially exposed person, unless either become symptomatic, at which time they should be separated.  The neonate should be monitored with twice daily rectal temperatures and assessed for signs of infection and other changes in behavior (e.g., not feeding well, excessive sleepiness, uncontrollable crying) as signs of many neonatal infections are often vague. Depending on the risk category, this monitoring may begin in the hospital and continue at home after discharge. Decisions to discharge the neonate should be made in conjunction with local public health authorities. Monitoring should continue until 21 days have elapsed since the person’s last known exposure to ebolavirus.

Routine care

For a neonate who appears healthy and stable after delivery, routine newborn care should be provided and non-invasive screening tests should be conducted.¹¹ Invasive screening tests and immunizations should be conducted as long as the patient and neonate remain asymptomatic. Circumcision should be delayed until the 21 days of monitoring have ended.

Breastfeeding Recommendations

A lactating person who is under evaluation for ebolavirus infection should not breastfeed until an ebolavirus infection has been excluded. Donor breast milk or Ready to Use Infant Formula (RUIF), if available, may be an acceptable substitute. To establish and maintain breast milk production during this time, the person may express breast milk. If pumping, the person must use a dedicated breast pump that remains in their room. The breast pump must not be used for any other person. Ebolavirus testing of the breastmilk should be conducted at regular intervals. Upon confirmation of ebolavirus infection, the guidance for a patient with confirmed Ebola disease should be followed.

Safe Handling of Breast Milk in Healthcare Settings

When a person is under evaluation for ebolavirus infection, PPE guidance should be followed for anyone handling the breast milk^9,16. The expressed milk of a person under evaluation for an ebolavirus infection is considered Category A infectious waste and must be disposed of in accordance with CDC guidance on waste management.¹⁷

Involvement of Family Members

A neonate born to an asymptomatic person with an ebolavirus exposure should be allowed visitors according to standard hospital protocol. In accordance with CDC guidance on Infection Prevention and Control Recommendations for Hospitalized Patients Under Investigation (PUIs) for Ebola Disease in U.S. Hospitals, visitors should not be allowed for a neonate born to a patient with confirmed Ebola disease until the neonate is beyond 21-days of age and determined to be uninfected.¹⁶ Visitors should not be allowed for a neonate born to a person under evaluation for ebolavirus infection until the person’s ebolavirus infection status is resolved. Consideration should be given to the use of visual observation through a window or use of videoconference technology, instead of in-person visitation.  If an exception is made for in-person visitation, PPE guidance should be followed.⁹

There is no known risk of transmission of ebolaviruses via breastfeeding for infants born to a person who becomes pregnant after recovering from Ebola disease.¹⁸

Breastfeeding is safe and should be recommended for people who, after recovering from Ebola disease, become pregnant and give birth.