Journal of Clinical Neonatology

EDIRORIAL
Year
: 2020  |  Volume : 9  |  Issue : 2  |  Page : 93--97

Recommendations for the management of newborn with suspected or confirmed coronavirus disease-19


Ali Almudeer, Jubara Alallah, Saad AlSaedi, Jasim Anabrees, Abdulhakiem Kattan, Zakariya AlSalam, Manal Asiri, Emad Khadawardi, Abdulrrahman AlMehery, Ibrahim Alhefzi, Abdulrrahman Alnemri 
 Neonatology Department, King Fahad Central Hospital, Jazan, KSA

Correspondence Address:
Dr. Ali Almudeer
Neonatology Department, King Fahad Central Hospital, Jazan
KSA




How to cite this article:
Almudeer A, Alallah J, AlSaedi S, Anabrees J, Kattan A, AlSalam Z, Asiri M, Khadawardi E, AlMehery A, Alhefzi I, Alnemri A. Recommendations for the management of newborn with suspected or confirmed coronavirus disease-19.J Clin Neonatol 2020;9:93-97


How to cite this URL:
Almudeer A, Alallah J, AlSaedi S, Anabrees J, Kattan A, AlSalam Z, Asiri M, Khadawardi E, AlMehery A, Alhefzi I, Alnemri A. Recommendations for the management of newborn with suspected or confirmed coronavirus disease-19. J Clin Neonatol [serial online] 2020 [cited 2020 Nov 25 ];9:93-97
Available from: https://www.jcnonweb.com/text.asp?2020/9/2/93/283030


Full Text



 Introduction



The following recommendation is provided by the Saudi Neonatal Society as a resource for the Kingdom of Saudi Arabia's health-care professionals working in neonatal field, based on the available evidence, good practice, and expert advice.

The goals are to:

Reduce the transmission of coronavirus disease-2019 (COVID-19) to newborn from their mothers and to health-care professional workers handling suspected/confirmed COVID-19 casesProviding a best access of care to the newborn with suspected/confirmed COVID-19 in their neonatal intensive care unit (NICU).

This guideline reflects the best current available knowledge about an evolving disease. It will be updated when new information becomes available.

 Transmission



COVID-19 is a novel respiratory pathogen that has emerged as a new strain of coronavirus, first identified in Wuhan City, China, and has resulted in an international pandemic. The mode of transmission between the cases of COVID-19 has strong evidence of human-to-human transmission. This virus was isolated from respiratory secretions, feces, and contaminated fomites. Recommendation and advice to the health-care providers on neonatal field are recommended to follow strict infection prevention and control measures. No evidence yet showed the possibility of vertical transmission (transmission from mother to baby antenatally or intrapartum).[1],[2][3],[4],[5],[6],[8] The study published by Chen et al. tested different samples including amniotic fluid, cord blood, neonatal throat swabs, and breastmilk from COVID-19-infected mothers, and all samples tested were negative for the virus.[1],[8] Furthermore, in a different article by Chen et al., swab was taken from the placentae of infected mothers, and the result was also negative for the virus.[7],[8]

There is no evidence of intrauterine fetal infection with COVID-19, so it is unlikely that there will be congenital effects of the virus on fetal development. In addition, there is no evidence currently that the virus can cause fetus anomaly. There are some case reports of preterm labor birth in women with COVID-19, but it is unclear whether the preterm birth was with other reason or happened spontaneously.[1]

 Labor Care



Currently, there is no published evidence of vertical transmission of the virus.[1],[2],[3],[4],[5],[6],[8] Therefore, if endotracheal intubation needed in a newborn confirmed to be a covid-19 positive personal protective equipment(PPE) should be followed by personnel. Virus will not be released by such procedure but the PPE is recommended. The neonatal team should be informed of any plan to deliver the baby of a woman affected by COVID-19 suspicious or confirmed, as far in advance as possible. The number of neonatal team attending the delivery is better to be minimized in the room to decrease the possibility of contact and senior personnel advisable to attend. There is no evidence against delayed cord clamping in such situation, if the the team plan to do delayed cord clamp it should be done with minimal or no skin to skin contact. The newborn should be resuscitated according to the current NRP guidelines.

 Resuscitation



Newborn required around 10% resuscitation at birth and if needed should be done according to the NRP. There are few local guidelines to approach newborns delivered to suspected mother or confirmed for COVID-19 in their pregnancy. Chinese health professionals decided to isolate the newborn for a period of 14 days from the diseased mother. This isolation and separation can affect the babies and mother in terms of breastfeeding, bonding, and mentally. Those data from china was from small data sample so approach should be carried out according to the mother situation if she is suspected or confirmed diseased with covid-19. Algorithm charts was modified from Canadian guidlines.[9] [Figure 1] showing approach care for the newborn without symptoms delivered to suspected mother. [Figure 2] showing approach to the symptomatic newborn.{Figure 1}{Figure 2}

 Infant Feeding



The evidence in this era should be interpreted cautiously. In one article including six Chinese cases, breastmilk was tested negative for the virus COVID-19.[1],[8] The main risk for the newborn on breast milk feeding from suspected or confirmed mother with covid-19 is through the respiratory droplet contact not from breast milk itsef. A mother with suspicion and under investigation or a confirmed case of COVID-19 should take all possible precautions to avoid spreading the virus to her infant via the following recommendations:

Handwashing before direct breastfeeding or pumpingCovering the face during breastfeeding by maskPreventing direct contact with the baby during breastfeeding (such as coughing or sneezing on the face)Proper pump cleaning measures are recommended post breast milk expressionSterilization guidelines are recommended if the mother is on bottle-feeding formula.

Based on the current and available data, breastfeeding benefits outweigh any potential risks of transmission of the virus through breastmilk.

 Neonatal Clinical Manifestations and Diagnosis With Coronavirus Disease-2019



Clinical manifestations

The incubation period of the virus is varying, with the minimum being 1 day and the maximum being 14 days.[9],[10],[11] Clinical findings can be asymptomatic, mild, or severe, and they can be nonspecific such as respiratory or gastrointestinal, mainly in premature babies. Vital signs can be affected by disease as thermal regulation can be disturb and newborn can has high, low or normal temperature. Respiratory rate and heart rate also can be above the normal range, showing tachypnea and tachycardia. Newborns can present with apnea, difficult breathing or cough or lethargy; poor feeding or feeding intolerance, and distended abdomen.

Basic laboratory investigations are nonspecific in COVID-19. Renal and liver functions can be affected such as increasing creatine kinase and elevated alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase. Hematological functions can also be affected such as decreased or normal leukocyte counts, decreased to normal lymphocyte counts, and mild decrease in platelet counts. Virus can be detected and isolated from blood, stool, or respiratory secretions swabs. Swabs can be taken from the upper respiratory tract like nasopharynx or from the lower respiratory tract through bronchoscope as bronchoalveolar lavage or endotracheal aspirate.

Radiographic findings

Finding features of pneumonia was documented in some cases and diagnosed by chest X-ray or lung ultrasonography. Intestinal ileus features also seen in some cases by abdominal X-rays.[1]

Definition of suspected coronavirus disease-2019

Newborns that suspected of COVID-19 infection regardless the symptoms, is the newborns that deliver to the mothers with a history of confirmed COVID-19 infection 14 days before birth or have the direct exposure to patients with confirmed infection with COVID-19 in the first 28 days of life (including family members or caregivers).

Definition of confirmed coronavirus disease-2019 infection

Newborns confirmed with COVID-19 infection should have positive test either by:

Real-time fluorescence polymerase chain reaction from blood or respiratory swabs Or positive virus gene sequencing for COVID-19.

 Neonatal Care



Health professionals working in the neonatal field should be aware and strictly follow the prevention and infection protocol including PPE and communicate very well in such cases.

Airway management

Different measures and precaution recommended to be available during airway management especially if procedures producing aerosols expected (like oral and nasal suction, positive pressure ventilation, noninvasive ventilation like CPAP or invasive ventilation such as endotracheal intubation, or if cardiopulmonary resuscitation needed or bronchoscopy needed for bronchoalveolar lavage, etc.).

The following measures should be available:

Isolation areaSuitable masksEye protective measuresSuitable gloves and long-sleeved suitsWell-ventilated roomSuitable head coverA senior health provider should be available and to minimize the number of the procedure trial.

Disinfection

Bags should be double layered for medical wasteThose wastes should be disposed off according to infectious medical waste protocol in the institutionRooms should be sterilized post discharge of the newborn according to the infection control measures in the institution.

Medical management

Those neonates with confirmed COVID-19 have to be admitted in the NICU isolation room, preferably with negative pressure. Currently, the main treatment is supportive care and treating the complications associated with the disease. Newborn who had respiratory distress syndrome showed better hospital course with high-dose surfactant. Some newborn requires inhaled nitric oxide, and high-frequency oscillatory ventilation. Newborn with renal impairment who were critically ill, may require continuous renal replacement therapy and extracorporeal membrane lung therapy. So multi-disciplinary team and advance neonatal level are recommended for the management of critical neonates with COVID-19 infection.[5]

 Neonatal Transport



The transport plan should be prepared by the designed team for such tasks in the region. Multiple levels of measures and steps should be taken including the type and number of ambulances, equipment, portable incubators, ventilators, monitors, supplies, and medication. Health providers' teams accompanying such babies must be trained very well on how to handle such cases including how to wear PPE.

 Neonatal Discharge



If the newborn is asymptomatic and swabs from the nasopharynx or pharynx or blood results show negativity toward COVID-19 virus for two times consecutively (with at least a 24-h interval), the baby can be discharged with follow-up according to algorithm charts.[12] Whereas for babies with confirmed COVID-19 infection and with symptoms, can be discharge after the symptoms clear.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2Chen Y, Peng H, Wang L, Zhao Y, Zeng L, Gao H, et al. Infants born to mothers with a new coronavirus (COVID-19). Front Pediatr 2020;8:104. [Doi: 10.3389/fped. 2020.00104].
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