NEO Conference 2021

Pediatrix NICU COVID-19

Preparation:
Real Time Response in
Uncertain Times
Dan Ellsbury MD
-National Director, NICU Quality and Safety, MEDNAX
Robert Ursprung MD, MMSc
-Director of HRO, Women’s & Children’s Services, MEDNAX
Disclosure
Drs. Dan Ellsbury, Robert Ursprung have no relevant
financial relationship(s) with ineligible companies to
disclose.
Objectives
Describe the recent history of the COVID-19
pandemic
Describe NICU-specific preparation for the COVID-19
epidemic
Describe concerns regarding quality of the medical
literature published during the COVID-19 pandemic
COVID-19: What happened?
January/February 2020
February 2020
China
 1,000 bed hospital constructed in 1 week!!!
China
China
COVID-19: Where are we now?
COVID-19: Feb 12, 2021
COVID-19: Preparing for Disaster?

Threat recognized
Great uncertainty
Trying to prepare for the worst
Pediatrix NICU COVID-19 Preparation Collaborative
Educational collaborative
Frequent discussion via “Neonatology Forum” email
discussion group
Dissemination and discussion of emerging COVID-19
literature
Provision of COVID-19 reference resources from multiple
groups and organizations
Weekly webinars to address various COVID-19 issues,
literature, topics of concern
 Best source for current coronavirus information
https://www.cdc.gov/coronavirus/2019-ncov/index.html

Examples of some of the initial materials

https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html
Examples of some of the initial materials
Examples of some of the initial materials
Examples of some of the initial materials
Examples of some of the initial materials
https://www.cdc.gov/
coronavirus/2019- Examples of some of the initial materials
ncov/hcp/healthcare
-supply-ppe.html
 https://www.hfma.org/topics/operat
ions-management/article/the-
coronavirus-and-the-supply-chain-
what-hospitals-need-to-know.html

Examples of some of the initial materials

Examples of some of the initial materials
https://www.raps.org/news-and-
articles/news-
articles/2020/2/coronavirus-will-the-
outbreak-lead-to-us-drug-sho
COVID-19: Preparing for Disaster?

Further delineation of threat

NICU specific preparation
Coronavirus (COVID-19) Information: MEDNX Resource page: April 2020
https://mednax.sharepoint.com/sites/communication
NICU Preparation: Thoughtful Pragmatism
• As neonatologists/NNPs, we hopefully will be spared from
caring for patients with COVID-19 severe respiratory failure
since it seems to preferentially impact the elderly and those
with other medical problems. But even if we luck out and
our babies do fine, we will have other problems to deal with
if there is a massive surge of critically ill patients in our
hospital system. What could happen? What can we
anticipate and plan for? This is hypothetical, but lets
consider a few things.
April 2020
NICU Preparation: Thoughtful Pragmatism
Ventilators:
• Demand for use in adults could result in fewer vents
available for our babies. This includes JET, HFOV too - those
could be utilized heavily for aRDS. How should we plan for
this? Aside from getting more ventilators, what else can we
do? Maximizing CPAP, vapotherm, bubble CPAP availability
(esp bubble) might be a wise step right now.

April 2020
NICU Preparation: Thoughtful Pragmatism
ECMO:
• ECMO use will likely go up as well in adults, not sure how
you can adapt, but certainly getting extra circuits is
advisable.

iNO:
• Nitric may be in high demand as well. Again uncertain how
to best prepare, but there may be things in your setting you
can optimize.
April 2020
NICU Preparation: Thoughtful Pragmatism
Referral Patterns:
• Do you send babies elsewhere for ECMO, iNO, certain
surgical procedures? Patient transfers could be delayed,
interrupted, or beset with triage problems of who goes
where. Anticipate, discuss, try to work out these things
before panic taints any discussions. If your NICU receives
transports to provide these types of procedures - how will
you respond if resources and limited?

April 2020
NICU Preparation: Thoughtful Pragmatism
Medications:
• It is likely that there will be shortages of a variety of medications,
due to supply chain disruptions from China and India. Anticipate
needing some flexibility and creativity on what drugs to use to get
around these shortages (some antibiotics and heparin may be a
problem).
Other medical equipment:
• It is quite possible that there could be a drain in equipment supply
due to supply chain problems. Try to make sure you have a good
supply of the essentials, if you can.
April 2020
NICU Preparation: Thoughtful Pragmatism
NICU beds:
• Could some of your NICU be taken over for use for adults or
pediatric patients? I would certainly hope not, but depending on
you NICU design and layout, that might be a possibility. Hopefully,
the model used in China and elsewhere to create temporary beds
would be utilized instead of ever considering using some NICU
space - but it is something to be aware of and avoid.

April 2020
NICU Preparation: Thoughtful Pragmatism
NICU RNs:
• This could be a major problem - your nurses could get pulled to
adult floors, causing significant disruption in your NICU staffing,
and infection risks if cross staffing.

Illness in co-workers:
• Illness in RNs, Neos, NNPs, RTs could cause major disruptions to
your care model. How would you adapt? Thinking about these
things now may be helpful.

April 2020
NICU Preparation: Thoughtful Pragmatism
Containment:
• How to contain COVID-19 if it is in your NICU, parents have it, staff
have it, you have it? It is highly transmissible. How will you deal
with this? The CDC is the best resource, and you will have to
follow local institutional guidelines. Familiarize yourself with the
guidelines so that when all of the situations that aren't clearly
discussed in the guidelines come up, you will be able to separate
fact from fiction.
Other Information
• A COVID international neonatal registry is being considered
• “Guidelines for Management of Infant Born to Mother with
COVID-19 from Children’s Hospital of Philadelphia”. Source: Karen
Puopolo MD
• Coding Guidelines: Have been distributed by Dr. Kanter
• Telehealth: See our COVID-19 Resource Page, also ongoing
discussions on the neonatology forum
• Staffing: See our COVID-19 Resource Page, also ongoing
discussions on the neonatology forum

April 2020
COVID-19 Preparation:

The Great Infodemic of 2020

“We’re not just fighting an epidemic;

we’re fighting an infodemic”
-Dr. Tedros Adhanom Ghebreyesus, the
Director-General of the World Health
Organization
Quantity of COVID-19 Publications
“A report that examined the
number of published articles in the
first 3 months of the pandemic,
starting from January 2020, showed
that within a period of 92 days a
total of 3201 articles were
published on this topic, and within
113 days, 6831 articles were
published; with an average of 34.8
articles and 58.89 articles per day,
respectively, this may be the
highest number for any disease so Pubmed search on 2/12/2021 for COVID or COVID-19 or
far” SARS-CoV-2: 102,991 results

J Clin Orthop Trauma. 2020 May; 11(Suppl 3): S304–S306.

Clin Exp Med. 2021 Jan 8 : 1–5.doi: 10.1007/s10238-020-00680-x
Quantity of COVID-19 Publications
What type of papers?

Jan-Nov 2020
• Original research papers (n = 4,841)
• Reviews, editorials, or meta-analyses (n = 13,890)

J Clin Orthop Trauma. 2020 May; 11(Suppl 3): S304–S306.

Clin Exp Med. 2021 Jan 8 : 1–5.doi: 10.1007/s10238-020-00680-x
Quality of COVID-19 Publications
Peer Review, Preprints
• Peer review
– Detailed data, statistical and methodological review of articles prior to publication
– Key component of the production of quality medical literature

• Preprints
– Publicly accessible scientific manuscripts that have not yet been certified by peer review
– Due to the delays from the peer review process, preprints facilitate the rapid communication of information
– Lack of peer review may result in the rapid dissemination of flawed articles and information
– The basic philosophy of preprints is that errors will get fixed as the scientific community comments on the
findings and that the advantages of rapid sharing among scientists balance the disadvantages of sharing invalid
findings
– The number of preprints has increased over 400% during the COVID-19 pandemic (from 586 for the last 15
weeks of 2019 to 2572 for the first 15 weeks of 2020)
Clin Exp Med. 2021 Jan 8 : 1–5.doi: 10.1007/s10238-020-00680-x
Toxicol Pathol. 2018;46(4):364–365.
Lancet Glob Health. 2020;8(5):e627–e630
BMJ. 2020;369:m1847
Quality of COVID-19 Publications
Fast Tracking Publications
• Fast tracking (rapid review and
publication) has been common
in the COVID era
• A study that analysed 8455
articles on COVID-19 indexed in
the PubMed database found
that 8% of the articles had been
reviewed and accepted for
publication on the day they
were submitted or the day
after, suggesting that in some
cases, the peer review process
had been rushed

Mayo Clin Proc. 2020;95(10):2288–2290.

https://www.biorxiv.org/content/10.1101/2020.08.13.249847v1.full.pdf
Quality of COVID-19 Publications
Retractions: withdrawal of published papers
• Retraction Watch: https://retractionwatch.com/retracted-coronavirus-covid-19-
papers/
• Retracted: 70 papers
• Retracted due to journal error: 10
• Retracted and reinstated: 4
• Expressions of concern: 5

https://retractionwatch.com/retracted-coronavirus-covid-19-papers/
Lancet 396(10257):1056
Scientometrics. 2020;125:1–4.
J Clin Epidemiol. 2008;61(5):464–470
COVID-19: Social Media Rapid dissemination of COVID information

Social Media: Rapid dissemination of

information (good and bad information)

Misinformation
• False information, shared without
knowledge that it is false

Disinformation
• Fabricated information distributed
with the clear intention to mislead

Ethics Inf Technol. 2020 Aug 26;1-8.

Clin Exp Med. 2021 Jan 8 : 1–5.doi: 10.1007/s10238-
020-00680-x
COVID-19: Social Media
COVID-19-related infodemic and its impact on
public health: a global social media analysis.
Am J Trop Med Hyg. 2020;103(4):1621–1629
• 2311 reports from a wide range of sources,
including fact-checking agency websites,
Facebook, Twitter, websites for television
networks, and newspapers on COVID-19 in
25 languages from 87 countries between 21
January 2020 and 5 April 2020.
• A total of 2049 (89%) of the reports were
classified as rumors, 182 (7.8%) were
conspiracy theories, and 82 (3.5%) were
classified as stigmatization of an affected
group Flattening the Infodemic Curve. WHO

Am J Trop Med Hyg. 2020;103(4):1621–1629

Psychol Sci. 2020;31(7):770–780.
World Health Organization (2020) https://www.who.int/news-room/spotlight/let-s-flatten-the-infodemic-curve
COVID-19:
Ongoing NICU preparation
Navigation through the infodemic
Stress and overload
Real time learning
Questions, many questions…
Frequent communication utilized to help clinicians sort
through the massive amount of COVID information
Webinars, email forums, slide sets
Changes in guidance, interpretation of guidelines, specifics
of protocols, equipment, etc – many questions, not many
evidence-based answers available
Stress, burnout concerns
Personal health and safety concerns
Screening: Regarding the CDC statements we discussed last week...
https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html
Last week the CDC website stated...

1. Pregnant women admitted with suspected COVID-19 or who develop symptoms concerning for suspected
COVID-19 during admission should be prioritized for testing.
2. Infants born to a pregnant woman with suspected COVID-19 for whom testing is unknown
(either pending results or not tested) are NOT considered to be infants with suspected COVID-
19.
3. Infants born to mothers with known COVID-19 at the time of delivery should be considered infants with
suspected COVID-19. As such, infants with suspected COVID-19 should be isolated from other healthy infants,
and cared for according to the Interim Infection Prevention…

This week... points 1 & 3 are unchanged. They deleted point 2.

• Pregnant women admitted with suspected COVID-19 or who develop symptoms concerning for suspected
COVID-19 during admission should be prioritized for testing.
• Infants born to mothers with known COVID-19 at the time of delivery should be considered infants with
suspected COVID-19. As such, infants with suspected COVID-19 should be isolated from other healthy infants,
and cared for according to the Interim Infection Prevention and Control Recommendations for Patients with
Suspected or Confirmed COVID-19.
April – May 2020
Symptom Status and
SARS-CoV-2 Test
Results among 215
Obstetrical Patients
Presenting for Delivery

April – May 2020

Universal Screening for SARS-CoV-2 in Women Admitted for Delivery
Separation of baby and mom… April – May 2020

AAP Guidance:
Maternal and newborn separation: While difficult, temporary separation of mother and newborn will minimize
the risk of postnatal infant infection from maternal respiratory secretions. Published data on newborn health
outcomes after birth to mothers with COVID-19 universally describe separation at birth, in many cases for prolonged
periods of time (Table 1); therefore, the risks of postnatal infection in the immediate newborn period consequent to
usual mother-infant care cannot be adequately assessed. The benefits of separation may be greater in mothers
with more serious illness. The likely benefits of temporary maternal and newborn separation at birth for decreasing
the risk of newborn infection should be discussed with the mother, optimally prior to delivery.

CDC Guidance
The determination of whether or not to separate a mother with known or suspected COVID-19 and her infant should
be made on a case-by-case basis using shared decision-making between the mother and the clinical team.
Considerations in this decision include:
• The clinical condition of the mother and of the infant
• SARS-CoV-2 testing results of mother (confirmed vs. suspected) and infant (a positive infant test would negate the need to
separate)
• Desire to feed at the breast
• Facility capacity to accommodate separation or colocation
• The ability to maintain separation upon discharge
• Other risks and benefits of temporary separation of a mother with known or suspected COVID-19 and her infant
 April – May 2020

Fig. 1: Infographic
showing maternal
clinical features,
possible modes of
spread to the neonate
and neonatal
management of
suspected or
confirmed COVID-19.
From: Perinatal
aspects on the covid-
19 pandemic: a Perinatal aspects on the
covid-19 pandemic: a
practical resource for
practical resource for
perinatal–neonatal perinatal–neonatal
specialists specialists. Mimouni, F.,
Lakshminrusimha, S.,
Pearlman, S.A. et al.
J Perinatol (2020).
https://doi.org/10.1038/s41
372-020-0665-6
Respiratory Equipment April – May 2020
Modifications
Filter attachment examples to Ambu and NeoPuff
 April – May 2020

https://perinatalcovid19.files.wordpress.com/2020/03/nicu-cv-19_resusc_airway-management-setuprt.pdf
 April – May 2020

Example from
Cook Children’s -

Set-up for transport

vent (Bronchotron)
 Pharmacologic
April – May 2020
Treatments for
Coronavirus
Disease 2019
(COVID-19):
A Review
JAMA. Published
online April 13, 2020.

Simplified Representation of
Severe Acute Respiratory
Syndrome Coronavirus 2 (SARS-
CoV-2) Viral Lifecycle and
Potential Drug TargetsSchematic
represents virus-induced host
immune system response and viral
processing within target cells.
Proposed targets of select
repurposed and investigational
products are noted. ACE2,
angiotensin-converting enzyme 2;
S protein, spike protein; and
TMPRSS2, type 2 transmembrane
serine protease.
COVID Therapeutics? Common Questions
Summary answers to common questions (See Reese’s email to Neonatology Forum on April1 for
details).

Non-steroid anti-inflammatory drugs - currently no scientific evidence establishing a link between

ibuprofen and worsening of COVID-19. If acetaminophen is an alternative it is recommended as the first
choice for management of pain and fever.

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) - We

don’t know enough. Until further data are available, ACE and ABRs inhibitors should be continued

Hydroxychloroquine - Despite the limited clinical data, given the relative safety of short-term use of
hydroxychloroquine, the lack of known effective interventions, and the in vitro antiviral activity, some
clinicians think it is reasonable to use hydroxychloroquine (or chloroquine) in hospitalized patients with
severe or risk for severe infection if they are not eligible for other clinical trials. The possibility of drug
toxicity (including QTc prolongation and retinal toxicity) should be considered.

Most comprehensive and consistently updated review of all reported (not proven) treatments
https://covidreference.com/treatment April – May 2020
COVID-19 Testing April – May 2020

https://theconversation.com/coronavirus-how-accurate-are-coronavirus-tests-135972
Questions… April – May 2020: Survey of COVID concerns
and questions, followed with Q&A sessions

• While cohorting PUI babies in a negative

pressure room, should we separate babies
born to COVID + mothers from those born
to PUI mothers, and is there a need to
separate PUI babies on room air from those
on breathing support?
Questions… April – May 2020: Survey of COVID concerns
and questions, followed with Q&A sessions

• Ideas for socially distancing in the NICU

while maintaining effective communication
with staff and families?
• Should NICU nursing and RT staff be
allowed or asked to provide care in adult
ICU or ER and be allowed to return to NICU
without being screened for COVID19?
Questions… April – May 2020: Survey of COVID concerns
and questions, followed with Q&A sessions

• We are often called to a delivery because baby

is requiring PEEP or PPV. Would you
recommend wearing N95, Face Shield, etc to
all these deliveries? Since we may not know
mom's status or she is asymptomatic.

• Does anyone have a handout on

recommendations for breast feeding? Yes –
will post to Neo Forum today
Questions… April – May 2020: Survey of COVID concerns
and questions, followed with Q&A sessions

• Reports of COVID positive infants with

Congenital Heart Disease? Have not seen
any reports, but certainly would be
considered high risk patients

• Are there any thoughts about the use of

Surfactant in the treatment of COVID?
Questions… April – May 2020: Survey of COVID concerns
and questions, followed with Q&A sessions

• What to do about restricting other visitors to babies (i.e. father

or other support person) in the situation of a COVID+ mom,
where the person in question is a "close contact". We have a
situation with a mom who delivered after being quite ill with
COVID and is still testing positive despite having recovered
and being discharged. Per AAP guidelines we are continuing
to restrict her access, but wonder about what to do with the
father, who is asymptomatic but continuing to interact with her
at home on a regular basis. AAP guidelines don't address this
specifically, or really the CDC even, other than that person
should pursue quarantining for 14 days since they are
exposed to a COVID positive person.
Questions… April – May 2020: Survey of COVID concerns
and questions, followed with Q&A sessions

• How to deal with the mental fatigue experienced

from processing information and daily changes
related to COVID 19?

• Anesthesia requesting that Neos stay in the

C/section OR for 30 minutes if the mother
receives general anesthesia? Why would we
agree to this?
Active COVID NICU Projects
MEDNAX NICU site survey. Initial survey request went out last Friday March 29 on the Neonatal Forum. We
ask all of you to participate for your units. There will be 3 rounds of this survey and having longitudinal data for
each NICU will be extremely useful for us and for public health purposes. If we have enough respondents this will
be the first national data regarding COVID-19 in the NICU. We have responses from 145 MEDNAX NICUs and
received expedited national approval for this survey from the Methodist IRB last week.

A National Registry for Surveillance and Epidemiology of Perinatal COVID-19 Infection has been
sent out from the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine (SONPM) list serve.
The Registry represents important research and is a collaboration between the AAP SONPM, the Vermont-Oxford
Network (VON), and MEDNAX. Barry Bloom is working with HCA NICUs to help them participate in this important
work. Information on how to register your hospital and team is available at:
https://services.aap.org/en/community/aap-sections/sonpm/ April – May 2020

VON SONPM Covid-19 Impact Audit. Vermont Oxford Network, VON, and the Section on Neonatal Perinatal
Pediatrics, SONPM, of the American Academy of Pediatrics are inviting newborn units around the world to
participate in a brief monthly online survey, the VON SONPM Covid-19 Impact Audit. The Audit will help hospitals
track the impact of Covid-19 on newborn care in their own newborn units, contribute important new knowledge
about the impact of the pandemic on neonatal care and allow teams to share what they are learning with
colleagues in the worldwide neonatal community. The first Audit will take place in April 2020 and be repeated
monthly. Hospitals will choose the day during the month for their local audit.
Pediatrix publication derived from COVID
surveys

Longitudinal Survey of COVID-19

Burden and Related Policies in
U.S. Neonatal Intensive Care
Units

Kaashif A. Ahmad, MD, MSc, Ashley Darcy-

Mahoney, Amy S. Kelleher, MSHS, Dan L.
Ellsbury, MD, Veeral N. Tolia, MD, and Reese
H. Clark, MD
Am J Perinatol. 2021 Jan; 38(1): 93–98.
Published online 2020 Oct 19.
Pediatrix publication derived
from COVID surveys

Impact of restrictions on
parental presence in
neonatal intensive care
units related to coronavirus
disease 2019

Ashley Darcy Mahoney, Robert D.

White, Annalyn Velasquez, Tyson
S. Barrett, Reese H. Clark, and
Kaashif A. Ahmad

J Perinatol. 2020; 40(Suppl 1):

36–46.Published online 2020 Aug
28.
The path forward…
It is unclear how long the pandemic will
persist. Your fortitude in caring for your
patients, your team, your family and
yourself will long be remembered – and
appreciated.

Hope is being able to see

that there is light despite
all of the darkness.
-- Desmond Tutu.
Thank you for your attention. Please
ask questions, provide comments
and share your insights with us.