MANAGEMENT OF NEONATE WITH COVID-19 IN NICU

This module is designed for management and prevention of complications in neonates likely to
be affected by COVID-19 as a result of outbreak of third wave. In an attempt to prevent
complications it is mandatory to ensure availability of man material resources and its
implementation.

AIM :
To improve the effective timely diagnosis, treatment, rehabilitation, preventive medical care and
quality management system.

The purpose of this protocol is to ensure the safety of patients who need neonatal critical
care during the COVID-19 pandemic, while protecting staff from infection. The processes
outlined here

OBJECTIVES
1. Protection of staff from exposure and infection
2. Conservation of PPE and resources
3. Mitigation of stress on staff and patients/families
4. General information/algorithms for care and treatment

GOALS
A. ensure proper airway
B. ensure adequate oxygenation n ventilation
C. maintain hemodynamic stability
D. prevention of infection
E. prevent further complications
 INTRODUCTION
The Transmission of SARS-CoV-2, to neonates is thought to be predominately to occur primarily
through respiratory droplets during the postnatal period when neonates are exposed to mothers or
other caregivers with SARS-CoV-2 infection. Limited published reports have raised concern
about possible intrauterine, intrapartum, or peripartum transmission Approximately 2-5% of
infants born to mother with positive COVID-19 have positive SARS-CoV-2 positive test in the
first 24-96 hrs. Their immature immune system leaves newborns vulnerable to other Severe
respiratory viral infections, which may cause severe disease among neonates.
This document provides interim guidance for the management of infants born to mothers with
confirmed or suspected COVID-19 infection.
Neonates born to the mothers who are suspected or confirmed COVID-19 infection can be
divided to three main groups:
1. Healthy baby
2. Asymptomatic infected (or mild disease) neonate born at or near term who does not require
neonatal intensive care.
3. Symptomatic or high-risk neonates requiring neonatal intensive care admission. (Preterm
infants)
ADMISSION PROCESS
1.Follow the admission criteria of NICU
2.All Patients under Investigation (PUI) or confirmed COVID patients that require NICU
admission will be evaluated and then admit.
● Direct Admissions from an outside hospital
A. Please remind all healthcare workers every time what are the requirements for PPE
B. At the time that a patient is accepted to the NICU.
C. See attached admissions algorithm n check-list
D. We will continue to adhere to all the same standards and protocols
E. when accepting a patient from an outside hospital /OR similar hospital (pediatric ward)
check the condition
F. A NICU Attending will accept a patient based on NICU admission criteria
G. The information will be communicated to the charge nurse to determine bed and staff
availability
H. Take high risk consent
I. Caretakers must be told about our visitor policy ( 1 visitor only) explain them the
language they understand to avoid unnecessary conflict and anxiety to families when
additional visitors are not allowed in.
J. Care taker should be with proper mask, gloves, and appropriate PPE.
K. Teach them about proper hand washing, use of sanitizer and proper distancing.

Clinical Manifestations:
 Clinical Findings:
Neonates with COVID-19 infection are classified according to the presence or absence of
apparent symptoms and signs. The clinical manifestations may be asymptomatic, mild, or
severe. Clinical findings, especially in premature infants, are nonspecific Therefore, it is
important to closely monitor vital signs, respiratory and gastrointestinal symptoms and signs.
 The signs may include:
a. Temperature instability: the temperature of an infected infant may be elevated,
depressed, or normal.
 b. Respiratory and cardiovascular signs may include tachypnea, grunting, nasal flaring,
increased work of breathing (WOB), apnea, cough, or tachycardia.
c. other findings may include poor feeding, lethargy, vomiting, loose stools, and
abdominal distension
 Laboratory finding:
Laboratory examinations may be non-specific.
Complete blood count (CBC) may show normal or decreased leukocyte counts, or decreased
lymphocyte counts.
Other findings may include: a. mild thrombocytopenia b. elevated levels of creatine kinase,
alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and lactate
dehydrogenase
COVID-19 can be detected by PCR:
a. Upper respiratory tract (URT; nasopharyngeal and oropharyngeal),
b. Lower respiratory tract (LRT; an endotracheal aspirate, or bronchoalveolar lavage)
c. The blood by serology test
d. The Stool by PCR
Radiography findings: a. Chest radiograph or lung ultrasound is likely to show pneumonia b.
Abdominal radiograph may show the characteristic radiographic features of intestinal ileus.

Healthy asymptomatic Neonate

 Newborns should be physically separated at birth from mothers with suspected or
confirmed COVID- 19 infection.
 The Healthy Asymptomatic Neonate should be admitted outside NICU to isolation room
with negative pressure. If an isolation room with negative pressure is not available, admit
in designated cohort room using HEPA filter in postnatal ward, infants should be placed
in air temperature-controlled incubator and maintained at least 6 feet / 2metres apart.
 Healthcare workers should use gowns, gloves, standard procedural masks, and eye
protection (face shields or goggles) when providing care for well infants
 Newborns should be bathed once the temperature is stable after birth to remove viruses
potentially present on skin surfaces.
 Promptly notify infection control team
  If the mother’s result is tested negative for COVID-19 infection and the neonate is
asymptomatic & stable: Transfer the baby to the mother / discharge the newborn with
follow up.
 If the mother’s result is tested positive for COVID – 19 infections: Collect the
Oro/nasopharyngeal swab for the newborn at 24hours of age and continue routine care.
 If the mother’s result is tested positive for COVID – 19 infections and the neonate
1st swab result is negative:
1. Repeat the 2nd swab at 48 hours.
2. If the neonate 2nd swab result is tested negative and the neonate is asymptomatic, discharge
the baby with negative caregivers (after 2 consecutive negative results)
3. If the neonate stays in the hospital, transfer the baby from the isolation room or discontinue
the isolation only after 14 days.
If the mother’s result is tested positive for COVID – 19 infections and the neonate 1st swab or
2nd swab result is Positive:
1. Repeat the sample every 48 - 72 hours until the swab results turns negative.
2. If the neonate is asymptomatic, discharge once negative for two consecutive samples to a
COVID– 19 negative caregivers.
In order to minimize PPE use and potential exposures in the postnatal care, routine newborn tests
newborn hearing screening are performed together.
Management of newborn infants born to suspected or confirmed COVID19.
Symptomatic Neonate requiring Neonatal Intensive Care
 Infants born requiring neonatal intensive care optimally should be admitted to a single
patient room with negative pressure (or using Hepa filter).
 If a single isolation room is not available, admit in designated cohort room using Hepa
filter in NICU, infants should be placed in air temperature-controlled incubator and
maintained at least 6 feet / 2metres apart.
 Promptly notify infection control team
 All attending healthcare workers must wear PPE before entering the room including a
gown, surgical mask, face shield, and gloves.
 Droplet precautions should be followed if the baby has respiratory illness where they will
be in an incubator until improved. This means a surgical mask (fluid resistance), gown,
gloves and eye protection (goggles).
 N95 masks are NOT required for health care worker during the routine care of
Symptomatic Neonate (if suspected or confirmed covid-19 positive mothers) even if they
require CPAP/ HFNO / mechanical ventilation.
 Surgical masks are adequate except in the aerosol-generating procedures. Surgical mask
required when patient contact, usual practice of gloves with nappy changes AND wash
hands thoroughly before and after handling the baby. It is acceptable to wear the mask for
4 hours or till your meal break as long as the mask remains dry. Note: surgical mask
should be used as a routine practice.
 For intubation or extubation / LISA or MIST / open suction / nasopharyngeal sampling -
N95 mask and goggles need to be used as well as gown and gloves (full PPE).
 Before initiating PPV or intubation, use a bag-mask device (or T-piece in neonates) with a
HEPA filter and a tight seal. The Endotracheal tube must be clamped while Switch from
Bag and mask ventilation to Mechanical ventilator.
 All body fluids and linens are treated as potential biohazards.
 Soiled linen should be disposed of according to COVID-19 Infection Prevention and
Control Measures.
 Lab investigations and diagnostic procedures should be requested based on the clinical
condition of the baby as indicated.
 If the mother’s result is tested negative for COVID-19 infection, transfer out the neonate
 from the isolation room and continue the close monitoring & supportive care
management.
 If the mother’s result is tested positive for COVID – 19 infections,
1. Collect the naso / orophargeal swab for the newborn at 24hours of age.
2. Continue the close monitoring and supportive care management
 If the mother’s result is tested positive for COVID – 19 infections and the neonate
1st swab result is negative:
1. Repeat the 2nd swab at 48 hours.
2. If the neonate 2nd swab result is tested negative, continue the supportive
care management.
3. Transfer the baby from the isolation room or discontinue the isolation only after 14 days

 If the mother’s result is tested positive for COVID – 19 infections and the neonate
1st swab result is Positive:
1. Continue close monitoring and supportive care management.
2. Repeat the sample every 48 - 72 hours’ intervals until the result turns negative
3. If the neonate is fit for discharge, Discharge with COVID – 19 negative caregivers
Once negative for two Consecutive samples.
4. Transfer the baby from the isolation room or discontinue the isolation after the
2 negative consecutive swab results.
 RESPIRATORY MANAGEMENT OF SICK NEWBORN

Practical approach to neonates with suspected or conformed COVID-19

Sr.No Respiratory Area
1 Bang and Mask
2 Suction
Oropharyngeal
3 Suction
Endotracheal Tube
4 C PAP
5 Endo tracheal
Intubation
6 Mechanical ventilation
Ventilation
Use Support
Labour room/OT Use as per NRP with full PPE.A small
bacterial/viral filter can be placed in the
outlet of self-inflatingbag. It creates dead
space so used smallest possible Do not use
when resuscitating less ELBW babies
Labour room/OT Continuous suction preferred over
/SNCU intermittent
SNCU Use inline suction
SNCU Use with viral filter at expiratory limb which
should be replaced every 12 hours
Labour This procedure is highest risk of aerosol
room/OT/SNCU generation so must
be performed by skillful person with
complete PPE .
Video laryngoscope is preferred as it helps to
maintain distance from patient while
intubating
SNCU Should be used as per indication with full
protection. A viral filter should be used at
the expiratory limb of ventilator.
.
 Asymptomatic Neonate
born to Covid
positive/Suspect Mother

Mother Sick Mother well

Mother with baby and full

Baby can be cared by respiratory and contact
No relative to take care
relative and EBM to be precautions during breast
given Admit in isolation feeding and care giving.
 BREAST FEEDING
Mother breast milk is the best nutrition to a newborn.
The main risk for infants of breastfeeding is the close contact with the mother, who is likely to
share infective airborne droplets.
1. Breastfeeding is not contraindicated at this time.
2. Mothers should be informed about the benefits of breast milk and the risk of newborn
infection with skin-to-skin contact.
3. If choose to breastfeed, mothers should perform hand hygiene before breastfeeding and wear
a mask during breastfeeding.
4. If an infected mother chooses not to nurse her newborn, she may express breast milk after
appropriate hand hygiene, and this may be fed to the infant by other uninfected caregivers.
5. Mothers of NICU infants may express breast milk for their infants during any time that their
infection status prohibits their presence in the NICU. NICUs should make arrangements to
receive this milk from mothers until they are able to enter the unit.
6. Breast pumps and components should be thoroughly cleaned in between pumping sessions
based on the manufacture guidelines that must include cleaning the pump with disinfectant wipes
and washing pump attachments with hot soapy water.
 PARENT VISITATION:
1. During the COVID-19 pandemic, most NICUs have appropriately limited parent presence and
non-parent visitation. Such restrictions minimize the likelihood that vulnerable infants in the
NICU will acquire an infection from a visitor with asymptomatic or symptomatic COVID19. In
addition, such policies protect the health and integrity of the specialized NICU workforce.
2. However, Parent visiting to NICU are allowed for 24/7.
3. Mother and father or any family members who Patient under investigation in regards to
COVID 19 (PUI) should not enter the NICU until their status is resolved.
4. Mother and father with confirmed COVID-19 should not visit NICU infants while able to
transmit COVID 19 Infections.
5. If the neonate is diagnosed to be a confirmed case of COVID-19 infection and parents are
tested negative for COVID -19 infection, the parents are not allowed to visit until the neonate has
been confirmed negative.
6. Video conferencing can be considered by NICUs who have limited visitation as a means for
families to see their child as well as communicate with the healthcare team.

ON DISCHARGE
 To strictly give exclusive breastfeeding up to 6 months of age.
 Avoid unnecessary handling of the baby and limit exposure with relatives.
 Maintain proper hand hygiene or alcohol-based rub.
 Strictly adhere to the immunization of child as per national immunization schedule.
 Follow-up in opd as per doctors advice.
-
 REFERANCES
1.Sankaran D, Nakra N, Cheema R, Blumberg D, Lakshminrusimha S. Perinatal SARS-CoV-2
Infection and Neonatal COVID-19: A 2021 Update. Neoreviews. 2021 May;22(5):e284-e295.
doi: 10.1542/neo.22-5-e1001. PMID: 33931474.
2. COVID19 India. Accessed 28 January 2021. Available at https://www.mohfw.gov.in/ 2. Guan
WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J
Med. 2020;382:1708-720. 3. Fox NS, Melka S. COVID-19 in pregnant women: Case series from
one large New York city obstetrical practice. Am J Perinatol. 2020;37:1002-04.
4. Raschetti R, Vivanti AJ, Vauloup-Fellous C, et al. Synthesis and systematic review of reported
neonatal SARS-CoV-2 infections. Nature Communications. 2020;11:5164.
5. Sheth S, Shah N, Bhandari V. Outcomes in COVID-19 Positive Neonates and Possibility of
Viral Vertical Transmission: A Narrative Review. Am J Perinatol. 2020;37:1208-16.