Here we discuss the care of a newborn born to a covid suspected/positive mother. The mother should be confirmed as covid positive by a positive RT-PCR test. If the test report is awaited and there is high suspicion of covid to the mother , then also all the below given precautions to be taken for both mother and baby.
Who is a suspected COVID-19 infant?
Newborn born to the mothers with a history of COVID 19 infection between 14 days before delivery and 28 days after delivery , or the newborn directly exposed to those infected with COVID 19.
Who is a confirmed COVID-19 infant?
Diagnosis of COVID 19 infection can be confirmed if one of the etiological criteria is met IRRESPECTIVE OF
a. Respiratory tract or blood specimens tested by RT-PCR are positive for COVID19 nucleic acid.
b. Virus gene sequencing of the respiratory tract or blood specimens is highly homologous to that of the known COVID19 specimens.
Resuscitation Care:
- Separate labour room and operation theaters are required for the management of covid suspected/ confirmed mothers.
- Mother should perform hand hygiene and wear triple layered mask.
- Required resources include space, equipment, supplies and trained health care providers for delivery and neonatal resuscitation.
- All the health care providers should follow standard universal precautions and full PPE should be used to prevent any kind of transmission.
- If possible resuscitation of the newborn can be done in a physically separate adjacent room earmarked for this purpose. If not feasible, the resuscitation warmer should be physically separated from the mothers delivery area by a distance of at least 2meters.
- Minimum number of personnel should attend the baby, one in low risk cases and 2 in high risk cases. They should use full set of PPEs.
- Once the baby is born, umbilical cord clamping should be done promptly.
- Skin to skin contact with the mother should be avoided.
- Follow standard neonatal resuscitation (NRP) guidelines. If PPV ( positive pressure ventilation) is needed, bag and mask (BMV) may be preferred over T-piece resuscitator.
- If the baby is stable, we can follow below given guidelines based on isolation facilities available in the place. If the baby is unstable, baby can be shifted to specially prepared isolation area of the NICU.
Care of the HEALTHY newborn in the postnatal period:
A. If resources for isolation is not available:
If resources for isolation of normal, suspected to be infected and infected mothers is not available OR health care facilities are overwhelmed because of large number of covid positive patients OR evidence of community spread is present,
a. Healthy newborn may be roomed-in with the mother.
b. The mother and baby dyad must be isolated from the other suspected and infected cases and healthy uninfected mothers and infants.
c. Direct breast feeding can be given
d. Aim for 2meter separation when mother not providing direct care for the baby.
e. Mother should wash hands frequently including before breastfeeding.
f. Mother should wear mask.
g. Mother should wash her breasts before feeding her baby.
h. Mother should keep her face away from her baby while coughing or sneezing during breastfeeding.
i. If both mother and baby are stable, early discharge to home followed by telephonic follow up/ home visits to be arranged.
B. If resources for isolation is available:
If resources for isolation for normal, suspected to be infected and infected mothers can be made available AND there is no evidence of community spread,
a. After immediate cord clamping, the baby should be isolated from the mother.
b. During isolation, the baby should be cared for by family member not in contact with the mother or other suspected/proven cases.
c. Mother can express breast milk after washing hands and breasts.
d. Mother should wear mask while expressing breast milk.
e. This expressed breast milk can be fed to the baby by cup or paladai under strict aseptic precautions (without pasteurization.)
f. Mother and baby can be roomed in 1)once mother has been tested and declared to be clear of infection. This is usually declared after 2 negative maternal RT –PCR tests >24 hours apart + resolution of fever/symptoms. 2) If the infant is also positive for covid19.
Care of the SYMPTOMATIC NEWBORN born to a mother with suspected/ proven COVID-19 infection.
a. Baby should be managed in a separate isolation facility.
b. Negative airborne isolation rooms are preferred for patients requiring aerosolization procedures like respiratory support/ nebulisation/ suction.
If negative pressure rooms are not available, 2-4 exhaust fans can be used to for driving air out of the room. Isolation rooms should have adequate ventilation. If room is air conditioned, ensure 12 air changes/hour and filtering of exhaust air. These areas should not be a part of the central air conditioning. Separate staffs should be posted only for this isolation room care. They should use complete PPE and should be trained for its safe use and disposal.
c. Respiratory support for such neonates should be based on lung protective strategy including non-invasive ventilation. Better to avoid NIPPV and HHHFNC.
USE OF ANTIVIRAL THERAPY / ADJUNCTIVE THERAPY IN NEONATES:
a. Management of a symptomatic newborn born to a covid suspected/ proven mother is mainly symptomatic supportive treatment.
b. The use of antivirals or chloroquine/hydroxychloroquine are NOT recommended in neonatal period.
c. Use of adjunctive therapy such as systemic corticosteroids and intravenous gamma globulin is NOT recommended in neonatal period.
CAN VACCINES BE GIVEN AT BIRTH?
a. BCG can be delayed for 2 weeks and be given when the baby comes for first follow up visit.
b. Routine injections of Vit K and Hep B can be given at birth itself.
CAN ROUTINE SCREENING BE DONE IN THEM?
a. All routine mandatory screening can be done in these neonates with all precautions. For example, routine physical examination @birth, daily rounds and @discharge should be done.
b. Newborn screening – S. Bilirubin, TSH and SpO2 screening should be done as per routine.
c. Postpone metabolic screening and OAE (hearing screening) for 2-3 weeks.
WHEN TO TEST THE NEWBORN FOR COVID-19?
a. No routine swabs to be taken from all neonates.
b. If mother’s RT-PCR comes positive (usually done in symptomatic covid19 suspected mother), then take swab from the baby also.
c. First sample at 24 hours after birth, if negative send second sample after 48 hours. Upper nasopharyngeal swab is the preferred sample for viral study.
d. No other routine lab investigations required for a stable newborn.
HOW TO DISCHARGE THEM?
a. If the baby is isolated from the mother from birth and 2 samples of RT-PCR 48 hours apart are negative, discharge to a healthy caretaker until mother has resolution of fever+improvement in signs/symptoms + 2 negative RT-PCR tests >/=24hours apart.
b. If the neonate is not isolated from mother at birth and 2 samples of RT-PCR 48 hours apart are negative, keep the baby with the mother with contact and droplet precautions until mother has resolution of fever + improvement in signs/ symptoms + 2 negative RT-PCR tests >/= 24 hours apart and can be discharged with the mother.
IF THE BABY BECOMES POSITIVE
a. If the mother and baby positive but asymptomatic, discharge them early if both of them are stable and if strict home monitoring is possible.
b. If the baby is symptomatic, the clinical condition of the baby should be assessed and decision should be taken accordingly. If the baby needs NICU care, that should be given with strict isolation protocols. Any kind of treatment facilities should be provided to the baby, with all proper safety measures.
ADVICE ON DISCHARGE:
a. Explain symptoms and danger signs of covid 19
b. Explain follow up plan clearly
c. Telephonic clarification of doubts and apprehensions after discharge to be arranged.
d. Local health care administration should be informed regarding these cases and proper follow up should be done by them.
e. DISHA number to be given to the family for any urgent help.