Perinatal And Neonatal Management Plan For Prevention And Control Of 2019 Novel Coronavirus Infection (1st Edition)

Original Article: Working Group for the Prevention and Control of Neonatal 2019-nCoV Infection in the Perinatal Period of the Editorial Committee of Chinese Journal of Contemporary Pediatrics (Zhou W-H, Email: zwhchfu@126.com), Chin J Contemp Pediatr, 2020, 22(2): 87-90.

Author of summary: Federica Fontanella & Francesca Bardi; Reviewer: Daria Di Filippo

Original Article Published on January 28th, 2020

Since December 2019, the novel coronavirus (2019-nCoV) infection has been prevalent in China. Due to immaturity of immune function and the possibility of mother/fetal vertical transmission, neonates are particularly susceptible to 2019-nCoV. The perinatal-neonatal departments should cooperate closely and take integrated approaches, and the neonatal intensive care unit should prepare the emergency plan to ensure the optimal management and treatment of potential victims. According to the national management plan and the actual situation, the Working Group for the Prevention and Control of Neonatal 2019- nCoV Infection in the Perinatal Period of the Editorial Committee of Chinese Journal of Contemporary Pediatrics puts forward recommendations for the prevention and control of 2019-nCoV infection in neonates.  

Cases of maternal infection 2019-nCoV have been identified, whereas, to date, there have been no reports of perinatal fetal infections and neonatal infections.The youngest child reported to date is 9-month-old. This recommendation is based on literature, on the national Class A infectious disease policy and on the law of infectious disease prevention the latest World Health Organization (WHO) principles

Perinatal treatment principles for suspected and confirmed pregnant women 

1.1. Process for Infants from Suspected 2019-nCoV mother

(1) If there is a prenatal suspected case, notify the neonatal department about the high-risk mother. Call the pediatrician in advance to allow enough time to prepare protective equipment. Preparing for neonatal resuscitation in the delivery room requires full protection (including head cover, goggles, protective clothing, gloves and N95 masks).

(2) in case of negative maternal test and good condition of newborn, the mother and baby can be stay to the same room. If the newborn responds poorly and has respiratory symptoms, then transfer the newborn to the Department of Neonatal for observation. If the mother is subsequently tested positive, the newborn should be admitted to an isolation ward for isolation and treatment.

1.2 Process for critical pregnancy cases

(1) Transfer immediately the mother to the intensive care unit in case of one of the following criteria: respiratory failure, septic shock combined with other organ failure.

(2) Postpartum isolation treatment: The mother is mainly treated by the infectious department, and the newborn is recommended to be isolated for 14 days. After isolation and treatment, breastfeeding can be considered.

(3) Maternal high fever and hypoxemia increase the risk of intrauterine distress and premature birth, hence the newborn should be closely monitored and isolation should be done on referral. Collect blood sample and respiratory secretions to detect the viral nucleic acids. Although no vertical mother-to child transmission is currently evidenced, the pathogenesis of 2019-nCoV infection may be similar to SARS and MERS, which have been reported in mother-to-child transmission. Therefore, the possibility of vertical transmission cannot be excluded.

2 Principles for the management of suspected and confirmed neonates

2.1 Diagnosis The clinical manifestations of neonatal infections, similar to those of adults are: asymptomatic, mild, or severe infection. Diagnosis requires the detection of a highly homologous sequence with known 2019- nCoV in the upper respiratory tract or lower respiratory tract.

(1) Infections are suspected in newborns born to the mothers with a history of 2019-nCoV infection 14 days before or 28 days after delivery, or the newborns directly exposed to those infected with 2019-nCoV (including family members, caregivers, medical staff, and visitors), regardless of whether they present symptoms or not.

(2) Diagnosis can be confirmed if respiratory tract or blood specimen is positive by RT-PCR or if virus gene sequencing of the respiratory tract or blood specimen is highly homologous to that of the known 2019-nCoV specimens.

2.2 Basic principles of prevention and medical management

(1) The newborn with a history of 2019-nCoV should be considered as suspected neonates when presenting cough and fever alongside with lung infiltration by chest X-ray. Laboratory tests should include RT-PCR for 2019-nCoV and other etiologies of infection (such as influenza viruses, respiratory syncytial virus, bacterium, etc.) should be ruled out.

(2) The newborn should be admitted to the quarantine ward if his/her mother has a history of 2019-nCov. Laboratory tests should include RT-PCR for 2019-nCoV.

2.3. Medical management

Currently there is no effective anti-coronavirus drug. Inappropriate use of antibiotics should be avoided. Intravenous gamma globulin can be used if necessary.

(1) Suspected and diagnosed neonates: admission to NICU, supportive care, treatment of complications, maintenance of homeostasis, and avoidance of intracheal intubation. Protective approaches include an effective quarantine room, contact – droplet and air isolation (for procedures involving aerosol).

(2) Treatment for severe neonatal cases: High dose of pulmonary surfactant (PS), inhaled nitric oxide (iNO), and high-frequency oscillatory ventilation (HFOV) may be effective for infants of severe acute respiratory distress syndrome. For critically ill cases, continuous renal replacement therapy (CRRT) and extracorporeal membrane lung (ECMO) therapy are recommended.

2.4 Discharge criteria

(1) Asymptomatic infection: Nasopharyngeal and pharyngeal swabs should be collected and tested every 2 days (with at least a 24-hour interval) until 2 consecutive results show negative.

(2) Upper respiratory tract infection: temperature normal for more than 3 days, symptoms improve, and specimens negative for two consecutive times (with at least a 24-hour interval).

(3) Pneumonia: temperature normal for more than 3 days, symptoms improve, and pulmonary imaging shows inflammation disappearing. Nasopharyngeal and pharyngeal swabs and sputum samples should show negative 2 consecutive times (with at least a 24-h interval).

3. Opinions on infection prevention and control

Strictly follow the requirements of the National Health and Health Commission’s “Guide for the Prevention and Control of New Coronavirus Infection in Medical Institutions (First Edition)” and “Guidelines for Common Medical Protection of New Coronavirus Infection (Trial)“.

3.1 Principles for prevention and control of infectious disease

(1) Outpatient triage and patient admission: Before neonates enter the department, doctors should determine which ward they should be assigned to. If those neonates present fever, they will enter the fever clinic.

(2) Transportation: ① Before the transportation, collect the infant’s medical history, especially whether he/she been contacted infected patient. ② If there is a contact with a suspected patient, and there are clinical manifestations, isolation will be recommended.

(3) Rule for visiting: ① ward visiting should be suspended. ② Family members can enter only after investigation by the hospital.

(4) Ward management: Suspected newborns should be isolated in a single room and confirmed cases should be admitted into separate rooms from suspected ones.

① Wards should be subdivided into transitional, quarantine, and general wards. Before neonates enter the ward, doctors should determine which one they should be assigned to according to the triage. Suspected neonates are suggested to be placed in an incubator: usage of an open rescue table should be prohibited. Individual items and nursing facilities should be separated.

② When entering and exiting the quarantine ward, hand hygiene should be strictly followed. Personal protective equipment should be taken. If the newborn has respiratory symptoms, medical staff should wear N95 mask and goggles when performing sputum suction and other operations. The contact of the patients should be minimized by bundling operations. A head cover should be placed on the suspected neonates using assistant ventilation. A negative pressure suction tube can be placed in the head cover, with the ventilator outlet connected to a filter through a negative pressure suction device. A closed loop sputum suction tube should be used. The resuscitation air bag should be connected to a filter.

3.2 Management principles of high-risk neonates

The high-to-low-risks of neonatal infection are: close contact, droplets (caregivers, family members, visitors), acquired infections in hospitals and in public places. For high-risk patients determine:

(1) Residence in or travel to areas where widespread community (such as Wuhan) has been reported in the prior 14 days

(2) Close contact with patients who come from where widespread community (such as Wuhan) and present fever or respiratory symptoms in the prior 14 days.

(3) Cluster and/or close contact with a confirmed or suspected case.

Patients who meet one of these conditions should be admitted to the quarantine ward for medical observation for 14 days (if the suspected or confirmed infection can be clearly ruled out based on clinical epidemiology, clinical and laboratory tests, etc., medical observation can be terminated in advance).

During the observation period, following instructions should be complied: ① Contact isolation and droplet isolation are necessary for all procedures during health caring. Air isolation should be carried out for those operations involving aerosol. ② The possibility of the vertical transmission cannot be ruled out. Infants should not be fed with the breast milk from mothers with confirmed or suspected of 2019- nCoV. Donor milk can be considered after pasteurized. ③Wastes produced by infants should be thrown in the double-layer bags labeled with infectious waste. Disinfect the wastes for more than 10 minutes by chlorine-containing solution before disposed as infectious waste (the concentration of disinfectant should follow the requirements for infectious diseases). ④ Non-disposable medical fabrics should be collected by the bedside and disinfected with chlorine-containing solution for more than 10 minutes and then be disposed as infectious medical fabrics. ⑤ To disinfect the patient’s room, atomized- or gasified- hydrogen peroxide and chlorine-containing solution are preferred.

3.3 Principles for suspected or confirmed cases during observation

If a neonate presents COVID-19 symptoms during the observation period:

(1) The neonate should be quarantined or isolated according to the procedures. The neonate should be transported to the assigned hospital with effective isolation and protection conditions.

(2) It is forbidden to admitted other infants in the ward before thoroughly disinfection.

(3) Other infants in the ward should be quarantined for medical observation until negative results. If the test for 2019-nCoV infection is positive, all infants in the ward should be quarantined for 14 days.