COVID-19 on Neonatal Unit

• Background
• Risk stratification
• Personal Protective Equipment (PPE)
• General Issues
• Testing the neonate
• Parents and visitors
• Babies born to Mothers with suspected/confirmed COVID-19
• Asymptomatic mother who has undergone routine testing
• Baby confirmed SARS-CoV-2 positive, regardless of respiratory status
• NNU baby with postnatal contact with a clinically suspected or confirmed case of COVID-19
• When to consider COVID-19 in a baby who deteriorates whilst receiving neonatal care
• Baby in the postnatal ward with a mother with clinically suspected or confirmed COVID-19

Background

There are limited data to guide the postnatal management of babies of mothers who tested positive for COVID-19 in the third trimester of pregnancy.

Pregnancies affected by SARS-Co-V are more likely to result in stillbirth or preterm delivery.. There have been four reported neonatal deaths attributable to SARS-Co-V infection, all during the delta wave. In the individual reported cases of possible vertical transmission, viral RNA in the infant’s respiratory secretions was not demonstrated before 36 hours of life. 

The newborn may become infected after birth, either from their mother, another family member or within the hospital setting. COVID-19 appears generally to be a fairly minor illness in young infants and may be asymptomatic. Infected infants will, however, be potentially infectious and there are concerns that illness could potentially be more severe in preterm or otherwise immune compromised babies. 

Current agreement with Y&H ODN is that babies should be managed in the most appropriate neonatal unit, as per current practice. There is no plan at present to have a Covid-19 unit.

This guidance is based on the latest available evidence and advice from Leeds Teaching Hospitals NHS Trust, Royal College of Obstetricians, Royal College of Paediatrics and Child Health, British Association of Perinatal Medicine and Public Health England.

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Risk stratification

National guidance recommends the following COVID-19 risk pathways, with aerosol PPE required for AGPs for both medium and high risk adult patients.

Given the negligible risk of perinatal transmission and small tidal volumes in the newborn, it is recommended that infants in the first 72 hours of life can be considered low risk unless their mother is confirmed or clinically suspected to be infected with SARS-CoV-2 .

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Personal Protective Equipment (PPE)

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General Issues

• See Delivery suite SOP – insert hyperlink
• Stabilisation/resuscitation at birth should follow current NLS/ARNI guidance.
• Babies on respiratory support, born to mothers with suspected/confirmed COVID-19 infection should be transferred in a closed incubator, if possible. All procedures should be in a single room with minimal staff.
• Babies born to mothers with suspected/confirmed COVID-19 infection that do not require medical intervention should remain with their mother.
• For babies with confirmed/suspected COVID-19 infection, to minimise risk of disease transmission, if required use
  • In-line suction
  • Video laryngoscopy

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Testing the neonate

• All mothers giving birth should be tested for SARS-CoV-2 infection on admission to hospital.
• The risk of false negative and false positive results from testing a newborn infant is significant.
• Admissions from delivery suite or postnatal ward do not require routine admission swabs
• Admissions from home/another hospital must be tested on admission. Admit into incubator and isolation room.
• Newborns admitted to the neonatal unit should not be routinely tested until 72 hours of age. Early negative samples are not definitive and positive samples should be confirmed with repeat testing.
• All infants undergoing AGPs should be tested weekly (Sunday night)
• Infants needing to go to theatre must have a Covid swab results available from the previous 72 hours.
• Patients needing emergency theatre should have a rapid test, available on the CAT unit.

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Parents and visitors

• COVID-19 positive parents must not visit their baby on the NNU. They should adhere to the current Trust isolation guidance.
• Parents have open access to their baby. Siblings can visit 2-7pm. Two other visitors may visit the baby during these times. The two visitors can be different each day.
• All parents, siblings and visitors should be asked if they are free from symptoms of infectious illness on entering the unit.
• Visits from other NHS staff and personnel to the NNU should be kept to a minimum – consider opportunities for remote meetings.

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Babies born to Mothers with suspected/confirmed COVID-19

At birth

• If the mother is under general anaesthetic aerosol PPE (gown, gloves, goggles & FFP3 mask) should be worn.
• If there are no maternal AGPs, droplet PPE (gown, gloves, goggles and fluid resistant surgical mask (FRSM)) is acceptable for airway positioning and oropharyngeal suction in the newborn.
• Aerosol PPE for all other neonatal airway procedures.
• Well babies only require testing if they become unwell. See below.

Baby requiring additional care

• Babies requiring additional care (e.g., intravenous antibiotics) should be assessed in the labour ward and a decision made as to whether additional care can safely be provided at the mother’s bedside. Avoid NNU admission if at all possible and safe.
• NIPE should be carried out as normal. NIPE is not an aerosol generating procedure (AGP see below) and visualisation of the soft palate should continue as usual

Neonatal unit admission

• Admit into isolation cubicle/cohorted area
• Admit into an incubator
• Use droplet PPE for routine baby cares if no AGPs
• Test for SARS-CoV-2 at 72 hours of age and 5 days. Testing soon after birth may not be reliable and is not clinically indicated.
• Send oropharyngeal or ET secretions rather than a throat swab
• If the baby’s condition deteriorates, or the respiratory disease is considered atypical after 24 hours of life, the baby may be screened for SARS-CoV-2 earlier.
• Clinical investigations should be minimised whilst maintaining standards of care.
• Until status is known all samples must be double bagged and labelled as possible Covid-19.
• If the mother tests negative, the baby should be nursed thereafter as normal.
• If the mother is confirmed positive and symptomatic, the baby should be considered potentially infectious and nursed in an incubator for 10 days, even if the baby tests negative.
• If the mother tests positive but remains asymptomatic, she should isolate for 10 days.
• If the mother tests positive, her partner and other family members do not necessarily need to self-isolate if they have received two doses of a COVID vaccination
• If the baby is asymptomatic at 72 hours, they can be moved out of an isolation room. They should remain in an incubator for 10 days or until discharge, whichever is sooner. If there is a deterioration, include SARS-CoV-2 respiratory PCR testing and consider isolation if respiratory support is required. 
• Skin to skin contact (no respiratory support) can be undertaken from 10 days after the onset of mother’s symptoms if she is well.     
• Discharge if the baby is well enough to an isolation room in the postnatal ward with their mother, or sent home to continue isolation, as clinically appropriate and with appropriate safety netting There are leaflets available on the RCPCH website.

Neonatal unit admission for respiratory support

• Aerosol PPE when directly caring for the baby
• Consider methods to reduce viral spread into the NNU including placing the expiratory limb of the CPAP into the incubator.
• Once the baby no longer requires AGPs, droplet PPE would be appropriate in the absence of a positive test. 
• Skin to skin contact on respiratory support should generally not be permitted while the infant is still potentially infectious.
• Skin to skin may be considered in exceptional circumstances. In this case, the mother will require to wear a FRSM, to protect both the baby and staff members. The baby should be cared for in an isolation cubicle and attending staff members should wear aerosol PPE.

Parents

• The mother should not attend the NNU until she has tested negative (if clinically suspected COVID-19) or (with confirmed infection) until 10 days (14days if she is an in-patient) after the onset of her symptoms and she is symptom free.
• Mothers who test positive for SARS-CoV-2 after they have been discharged need only self-isolate for 10 days from the onset of symptoms or (if asymptomatic) from the date of their positive test. 
• Partner: If the mother tests positive, the partner (if they have had 2 vaccinations) should test negative and do daily LFTs before visiting. They can still continue to be with their baby.

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Asymptomatic mother who has undergone routine testing

Mother tests positive

• The infant should be isolated, tested and managed according to the guidance above

Mother’s test awaited
At birth

• Droplet PPE (FRSM, gown, gloves) for all airway procedures. FFP3 mask is not required

Baby requires NNU admission

• Baby without respiratory distress – no need to isolate, but if facilities permit, it would be reasonable to place them in a cohort room with other infants whose mothers are awaiting test results. Nurse in an incubator and monitor for signs of COVID-19. If the infant develops signs, or if the mother’s test result is reported as positive, they should be isolated and tested (see guidance in preceding sections).
• Baby who requires respiratory support (AGP) < 72 hours of age. The risk of the baby being infected/infectious is very low; it is reasonable not to isolate the baby, but simply to nurse in an incubator and to use droplet PPE. In areas where the prevalence of SARS-CoV-2 is high, or when the mother has a confirmed COVID-19 contact, Trust guidelines may mandate that the baby is isolated and aerosol PPE worn. 

Mother tests negative

• No need to isolate.
• If there is subsequent clinical concern that an infant is not following a typical clinical course, or that the mother has developed symptoms, both the mother and infant should be tested and the baby isolated.

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Baby confirmed SARS-CoV-2 positive, regardless of respiratory status

• Admit to an isolation cubicle or a cohorted area and nurse in an incubator. 
• Minimise handling as far as possible with clustered cares.   
• If no respiratory support, droplet PPE
• Aerosol PPE for AGPs. 
• In the event of acute collapse, aerosol PPE should be donned before undertaking intubation. If the baby does not respond to airway positioning manoeuvres, oral suctioning and facial oxygen it would be reasonable to undertake bag mask ventilation wearing droplet PPE with the baby in the incubator, whilst waiting for other staff to don aerosol PPE. 
• The baby should remain in isolation for 10 days
  If the tests on day 3 and 5 are positive and the requirement for respiratory support continues beyond 14 days, the infant can come out of source isolation (14 days after the first positive test) but should remain in an incubator, where possible, until no longer undergoing AGPs.
• Skin to skin contact should generally be avoided while the infant requires ongoing respiratory support but may be considered in exceptional circumstances.   

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NNU baby with postnatal contact with a clinically suspected or confirmed case of COVID-19

• Postnatal contact is defined as physical contact (within 2 m) of at least 15 minutes’ duration with any person who develops suspected or confirmed COVID-19 within the following 48 hours.
• Test potential source for SARS-CoV-2 – if negative, no further action (as long as baby is asymptomatic). If symptoms persist and likely to represent COVID-19, consider a repeat test. 
• If source is positive and the infant is asymptomatic (on NNU for non-respiratory reasons or improving respiratory status with anticipated non-COVID-19 pathology), they should be immediately isolated (incubator care) and observed for signs of respiratory distress or other features that might suggest neonatal COVID-19 for the next 10 days (or discharge, whichever occurs first). If the baby develops signs at any stage, they should be tested for SARS-CoV-2. They should have a PCR test 72 hours after exposure., They
• If one or other parent is the contact, and they have not been admitted to hospital with COVID-19, they will require to isolate for at least 10 days.
• Skin to skin contact is permissible with either parent (or both parents) if they are not the suspected or confirmed contact and should be encouraged in the usual way.

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When to consider COVID-19 in a baby who deteriorates whilst receiving neonatal care

• Many of the signs of COVID-19 are common signs in preterm or sick term babies. Screen for SARS-CoV-2 any symptomatic baby who has a known contact with someone who has or may have COVID-19, or any baby who displays an unusual clinical course.  
• Screen and isolate as per baby of a mother with suspected or confirmed COVID-19.

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Baby in the postnatal ward with a mother with clinically suspected or confirmed COVID-19

• Droplet PPE. 
• The NIPE is not an AGP (including inspection of the palate). Full visualisation of the palate should be undertaken as normal, using a tongue depressor if required. 
• Mother should be advised to wear a mask when feeding baby, and to practice good hand hygiene.
• Breast feeding is encouraged. If the mother is coughing, she should be wearing a FRSM. 
• Discharge early if the mother is well – ensure as many routine procedures as possible are undertaken before discharge, and/or that mechanisms are in place for prompt review in the community. Provide good safety-netting advice. The baby should be considered potentially infectious for 10 days from birth. 

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