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A neonate is said to be a COVID-19 exposed neonate if he/she is
The following SOP is based on IAP/NNF guidelines and existing literature as of 14/4/2020 and will be discussed under the following headings.
A. Delivery room/ Operation theatre
B. Postnatal isolation ward
C. Isolation area
D. Health Care Team
E. Disinfection
F. Testing
G. Other practices
H. Outborn babies
I. Discharge
J. Safe management of a dead body
A. DELIVERY ROOM/ OPERATION THEATRE:
• Layout:
➢ 2 physically separate dedicated rooms to be kept for delivery of COVID-19 suspect/
confirmed pregnant mothers. The newborn care corner/ resuscitation area should be set up in this room.
➢ MTP operation theatre (MTP OT) to be kept aside for LSCS for suspect/ confirmed
COVID-19 cases. The resuscitation area should be placed away from the mother’s delivery table at a minimum distance of 2 meters (6 feet).
• Designated resuscitation team:
➢ The neonatology/newborn team should be informed STRICTLY 30 to 60 minutes before delivery.
➢ Minimum number of personnel should attend the delivery (1 in the low-risk case and 2 in high-risk cases).
➢ In the case of 2 personnel attending a delivery, one personnel will enter the LR/ OBOT with minimal equipment, while the other person is stationed at the door with the remaining equipment. He/she will be summoned inside in case of an emergency.
➢ A full set of PPE should be worn when attending delivery.
• Delivery:
➢ If prenatal counseling is required, the same should be done via phone/ video to minimize exposure to health care workers.
➢ The mother should perform hand hygiene and wear a triple layer surgical mask.
➢ Delayed cord clamping should be performed as per WHO recommendations
(minimum 60 seconds or till the cessation of umbilical cord pulsations)
➢ Skin to skin contact could be initiated immediately after birth after a detailed discussion with the relatives as per WHO guidelines.
• Resuscitation:
➢ A separate set of resuscitation equipment to be kept aside for suspect/ confirmed COVID-19 cases.
➢ OBG/ Neonatal resident will bring the neonate to the resuscitation area for assessment.
➢ Standard NRP protocols (2015) should be followed for the resuscitation of the neonate.
➢ If positive pressure ventilation is required, Self Inflating Bag and mask with open reservoir is preferred over a T-piece resuscitator. If a closed reservoir is used, it is to be discarded after use.
➢ When giving bag and mask ventilation, low tidal volumes should be given to reduce aerosolization of secretions.
➢ Used self-inflating bags are to be kept in H2O2 solution until it is sent for Ethylene
Oxide sterilization.
• Ventilation
➢ CPAP should be preferred as a non-invasive ventilation mode over NIMV &
HHHFNC to minimize aerosol generation. CPAP should be delivered with the minimum flow rate required to achieve the desired pressure.
➢ A separate bubble CPAP machine to be allotted for use only for suspect/ confirmed COVID-19 cases.
➢ Intubation should be considered early in cases of CPAP failure. The most experienced provider should perform intubation and other procedures to limit aerosol generation.
➢ 3 gloves technique should be used for intubation – 3 gloves to be worn at the
beginning of the procedure - the outer glove is used for the procedure and
discarded, the middle one is used for disinfecting the equipment (laryngoscope, etc) and then discarded, while the inner one is used for personal safety.
• Minimizing exposure:
➢ An early bath/ sponging with lukewarm water to be done to minimize exposure in stable term newborn infants born to a mother with suspected or confirmed COVID- 19.
• Transport:
➢ Transport of the neonate to isolation area should be done in a closed transport incubator allotted only for suspect/ confirmed COVID-19 cases and should be accompanied by a doctor in full PPE.
B. POSTNATAL ISOLATION WARD:
• The ward designated for COVID-19 maternity cases is the current PPS ward.
• Admission:
➢ Stable neonates with exposure to COVID-19 infected cases should be roomed-in
with their mothers.
➢ The mother-baby dyad should be isolated from other infected cases (isolation ward 4A) as well as other healthy uninfected mothers and neonates (PNC ward 14A).
• Feeding:
➢ Stable neonates roomed in with the mother should be exclusively breastfed.
➢ While breastfeeding, the mother should ensure the following
▪ Hand hygiene before and after feeding
▪ Respiratory hygiene (coughing/ sneezing into handkerchief/ elbow)
▪ Wear a mask
➢ If breastfeeding is not possible as in cases of sick mother/ neonate, expressed breast milk can be fed to the neonate by healthy HCW/ relative.
➢ The expression should be done after washing hands and breast, and wearing a mask, by manual expression or using a dedicated breast pump.
➢ Expressed breast milk can be given without pasteurization to her baby.
• Immunization:
➢ Healthy neonates born to mothers with suspected/ proven COVID-19 infection
follow routine immunization.
➢ Neonates with suspect/ proven COVID-19 infection – follow routine immunization
• Visitors:
➢ Visitors should be kept to a minimum and screened for symptoms before entry into a postnatal isolation ward.
➢ Parents/ relatives who are suspected/ confirmed cases should not be allowed to enter.
C. ISOLATION AREA:
• The area allotted for the admission and management of COVID-19 exposed neonates who are symptomatic/ sick is the current PPS ward.
• Layout:
➢ Symptomatic neonates with mothers having suspected/ proven COVID-19 infection should be managed in an isolated area.
➢ Suspected and confirmed cases should be segregated, and physically separated from each other by a physical barrier or screen.
➢ All beds in the isolated area should be separated by a minimum distance of 1 meter (3 feet) between beds.
➢ Isolation room should have negative pressure ventilation, which is created by the use of 2-4 exhaust fans driving the air out of the room.
➢ The isolation room should not be part of the central air conditioning, and all ducts and vents should be physically closed.
➢ The room should be air-conditioned with 12 air changes per hour.
• Personnel:
➢ The doctors, nursing, and support staff should be separate from the ones who are working in a regular NICU.
➢ The staff should be provided with adequate supplies of PPE and wear full PPE
throughout the shift.
➢ All staff should be trained for safe use and disposal of PPE.
➢ The correct technique for Donning and Doffing of PPE should also be followed strictly.
• Management:
➢ Investigations - CBC/ CRP/ chest x-ray/ blood culture/ AST/ ALT/ CK-MB to be
sent for all babies after senior advice – look for leukocytosis, lymphopenia,
thrombocytopenia, elevated transaminases and CKMB. Chest x-ray (if indicated)
may show diffuse ground-glass appearance.
➢ Respiratory support for neonates should be guided by the principles of the lung protection strategy. NIMV and HHHFNC should be avoided.
➢ Aerosol Generating Medical Procedures (AGMP) such as intubation, extubation, invasive/ non-invasive mechanical ventilation, Bag and mask ventilation, cardiopulmonary resuscitation, suctioning and surfactant administration, should be done with utmost care wearing full PPE.
➢ Intubation should be done using Rapid sequence intubation technique – pre-procedure Fentanyl and Midazolam to prevent coughing, gagging, or retching (as they can lead to aerosolization).
➢ Muscle relaxants for paralysis should be used only after senior advice.
➢ 3 gloves technique should be used for intubation – 3 gloves to be worn at the
beginning of the procedure - the outer glove is used for the procedure and
discarded, the middle one is used for disinfecting the equipment (laryngoscope, etc) and then discarded, while the inner one is used for personal safety.
➢ Auscultation of chest to confirm tube position should not be done. Tube position to be confirmed by the presence of misting in the tube, chest rise and improving saturation, and subsequently with an X Ray.
➢ Extubation should follow the same 3 glove technique – with a sheathing of ET tube immediately after removal to reduce aerosolization.
➢ Inline Suctioning to be used for intubated neonates who are COVID-19 exposed. If open suctioning is done, use sedation and paralysis (after senior advice) before the procedure.
➢ HME filters should be used with all ventilator circuits, as well as with Bag and mask ventilation, to reduce contamination. They may be used for 48-72 hours before needing to be replaced.
➢ Kangaroo mother care should be avoided in view of the restricted entry to the isolation area.
➢ Relatives should be counseled on a periodic basis with updates on isolation,
monitoring, diagnostic and treatment plan of the baby.
➢ Relatives/ attendants should not be allowed entry to the isolation area.
• Novel therapies:
➢ Antivirals or Hydroxychloroquine/ Chloroquine are not indicated in symptomatic neonates with suspected/ confirmed COVID-19 infection.
➢ The use of therapies such as systemic corticosteroids & Intravenous Immunoglobulin is not recommended in symptomatic neonates.
D. HEALTH CARE TEAM:
• Team – 5 resident doctors, 1 faculty, 3 nurses, 1 class IV worker
➢ 4 resident doctors doing shifts in rotation (morning/ afternoon/ night/ off)
➢ 1 resident doctor standby
➢ 1 faculty supervising and advising telephonically
➢ 1 staff nurse in each of the three shifts.
• Scrubs should be worn during duty hours with PPE on top. All street clothes to be kept outside isolated areas.
• Complete set of PPE to be worn at all times inside the isolation area, and will include Protection Suggested PPE
• Respiratory protection Triple-layer surgical mask ; N95 to be used when performing aerosol generating procedures or in areas where neonates
are being given respiratory support.
• Eye protection Goggles or face shield
• Body protection Long sleeve water-resistant gown
• Hand protection Gloves
• Technique for Donning PPE is as follows:
➢ Proper hand hygiene should be performed.
➢ The gown should be donned first.
➢ The mask or respirator should be put on next and properly adjusted to fit; remember to fit check the respirator.
➢ The goggles or face shield should be donned next.
➢ A pair of sterile gloves are donned last.
• Technique for Doffing PPE is as follows:
➢ Alcohol-based hand rub → remove gloves → perform hand hygiene → wear clean gloves
➢ Unbutton backside of the gown and remove – assistant
➢ Remove goggles – place fingers beneath elastic strap at the back of the head
➢ Remove respirator/ mask – place finger/ thumb beneath elastic straps in the back of the head
➢ Alcohol-based hand rub → remove gloves → perform hand hygiene
• Dispose of all PPE in YELLOW bag after use – to be sent for incineration.
• Health care workers should consider Hydroxychloroquine prophylaxis as per ICMR recommendation on 22/3/2020.
• He/ she must report immediately if any respiratory symptoms.
• He/ she will be replaced by a healthy standby and will follow institutional protocols for testing.
E: DISINFECTION:
Disinfection of the premises is vital to reduce exposure to healthcare personnel as well as readiness to admit and shift new patients. It’s important to know that the cleaning personnel should wear full PPE (Personal protective equipment) before carrying out the disinfection of the nursery or pediatric ward. All the equipment or surfaces visibly soiled should first be cleaned with soap and water or a soaked cloth before applying the disinfectant.
After that, sodium hypochlorite solution should be used for the disinfection of large surfaces including floors and walls. The solution should have a minimum concentration of 5000 PPM. It can be made easily by adding 100 ml of standard 5% solution to 900 ml of water. The surfaces need to be cleaned at least once every shift.
For moderate-sized equipment surfaces like radiant warmer, infusion pumps, SpO2 monitors, phototherapy units and shelves, a solution of hydrogen peroxide can be prepared by adding 100 ml of the standard hydrogen peroxide (10% solution) to 900 ml of distilled water. This solution should be kept applied for at least 1 hour to ensure proper disinfection; it is to be used before and after use for each patient.
For small surfaces like radiant warmer, SpO2 monitor probes, stethoscopes, thermometer, and BP cuffs, the use of any disinfectant containing at least 70% ethyl alcohol is recommended before and after each use.
F. TESTING:
• Testing of neonates for COVID-19 infection should be done as follows.
Who?
• Neonates born to mothers with COVID-19 infection within 14 days
of delivery or up to 28 days after birth
• Symptomatic neonates exposed to close contacts with COVID-19
infection
When?
• If symptomatic/ transferred to NICU, specimens should be collected
as soon as possible
• If asymptomatic, test only if and when the mother’s test comes positive.
• If the mother is COVID-19 positive and the baby’s initial sample is negative, another sample should be repeated after 48 hours.
What sample?
• Not mechanically ventilated - Nasopharyngeal swab (NP).
• Mechanically ventilated - Tracheal aspirate sample
How to collect?
Nasopharyngeal swab
• Use only synthetic fiber swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden shafts, as they may contain substances that inactivate viruses and inhibit PCR testing.
• Insert a swab into the nostril parallel to the palate. The swab should reach depth equal to the distance from nostrils to the outer opening of the ear.
• Leave the swab in place for several seconds to absorb secretions. Slowly remove the swab while rotating it.
• Place swabs immediately into sterile tubes containing 2-3 ml of viral transport media. Other samples (stool, urine, and blood specimens) – Not advised.
Labeling
• Label each specimen container with the patient’s name, hospital ID
Sample number, specimen type, and the date the sample was collected.
How to store?
• Samples should be collected in viral transport media and transported immediately in ice packs.
• One can use disposable thermocol cartons or plastic bags with ice cubes for in-house transport.
• If sending to another laboratory, store specimens at 2-8°C for up to 72 hours after collection in a dedicated refrigerator.
• If a delay in testing or shipping is expected, store specimens at -70°C or below in deep freezers.
What test?
• Reverse Transcriptase PCR (RT PCR) test for detecting COVID-19
G. OTHER PRACTICES:
• Antenatal Steroids
➢ Currently, no evidence to support or refute the use of ANS in mothers with suspect or confirmed COVID-19 infection with impending preterm delivery.
▪ <32 weeks – give steroids
▪ 32-34 weeks & mother had no/ mild symptoms – give steroids
▪ 32-34 weeks & mother has severe symptoms – withhold steroids
▪ ≥34 weeks – withhold steroids
• Antenatal Magnesium Sulphate
➢ There is insufficient evidence to support or refute the use of antenatal MgSO4 for impending preterm delivery <32 weeks.
H. OUTBORN BABIES:
• Neonates presenting from other hospitals/community with symptoms of COVID-19
infection or with a history of contact with a suspect/ confirmed case should be admitted to the isolation area.
• NP swabs should be collected and sent at admission.
• CBC/ CRP/ chest x-ray/ blood culture/ AST/ ALT/ CK-MB to be done if indicated,
after senior advice.
I. DISCHARGE:
• Stable neonates who are roomed in with the mother should be discharged together at the time of the mother’s discharge.
• Stable neonates in whom rooming-in is not feasible (due to mothers' sickness) are cared for by a trained family member and discharged after 24-48 hours of age.
• Parents and relatives should be educated about the importance of isolation, hygiene, and testing/ follow up, as well as reporting to hospital in case of danger signs
J. SAFE MANAGEMENT OF DEAD BODY:
• PPE to be worn during the handling of the body. Shift as early as possible from the ward.
• Autopsy is not necessary and embalming is not recommended.
• Treat with respect and dignity. Respect religious and cultural sentiments.
• Clean and disinfect using a 1% Sodium hypochlorite solution (200 ml hypochlorite solution + 800 ml water).
• Place dead body in a zip body bag, Disinfect and decontaminate body bag from outside.
• Decontaminate carrying tray and trolley post-transfer with 1% hypochlorite.
• Relatives may be allowed to view the body from a distance of 1 meter. They should not touch or kiss the body.
