Guidance for Neonatal Services

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This guidance is for NSW neonatal services and is focussed on the care of newborn babies born to women with suspected or confirmed COVID-19 in the acute healthcare setting. The criteria for suspected or confirmed cases of COVID-19 is clearly defined by NSW Health.  

This guideline is based on a combination of available evidence to date on COVID-19. The importance of uncertainty is acknowledged, and this guideline will be subject to change over the course of the pandemic as new evidence emerges. The guideline focuses on specific considerations for neonatal services relevant to the COVID-19 environment and does not provide detail on specific clinical procedures. For Information on infection prevention and control practices see the Clinical Excellence Commission (CEC) Infection Prevention and Control webpage.

This guideline should be used in conjunction with the following NSW Health documents:

NSW Health endorses the use of the Queensland Clinical Guidelines 'Perinatal care of suspected or confirmed COVID19 pregnant women'; Section 2 'Maternity care during COVID-19 pandemic' and Section 4 'In-hospital maternity care for suspected or confirmed COVID-19 cases'.

  • Clinical Excellence Commission (CEC) 'COVID-19 Infection Prevention and Control: Maternity and Neonatal Services' (currently in draft)

General Principles

Table 1 General Principles

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Issue​​ Consideration
Babies of women who are NOT suspected nor confirmed to have COVID-19​

Newborn babies of women NOT suspected nor confirmed to have COVID-19, should receive routine care

 
Case definition

For current case definition and testing criteria for COVID-19, see the NSW Ministry of Health website.

 https://www.health.nsw.gov.au/Infectious/diseases/Pages/2019-ncov-case-definition.aspx
Unintended consequences Service redesign or changes to models of care need to be accompanied by a robust risk assessment process to ensure there are no unintended adverse consequences of such changes.
Infection prevention and control practices Healthcare facilities should ensure appropriate infection prevention and control practices for Maternity and Neonatal Services.  Detailed guidance is available on the Clinical Excellence Commission (CEC) Infection Prevention and Control webpage

Risk Management (newborn baby of a woman with suspected or confirmed COVID-19)

Table 2. Risk Assessment and Care Planning

Issue​ Consideration
Risk Assessment A baby born to a woman with suspected or confirmed COVID-19 is considered a close contact of the woman (even if the dyad is separated at birth). The baby requires precautions (not necessarily separation) in the acute healthcare setting or at home for at least 14 days after birth.  Consult with clinical microbiologist or infectious disease specialist on case by case basis.
Care Planning

It is recommended that the following specialities convene to regularly review the plan for birth, postnatal care and discharge of an admitted woman with suspected or confirmed COVID-19 and her baby/babies:

    • obstetrics/midwifery
    • neonatal/paediatrics
    • clinical microbiologist/infectious disease physician
    • infection prevention and control staff

      This plan must include support for the woman and her partner or support person, and provide identification of an alternative family member who may need to take responsibility as primary caregiver of the baby.

Initial Care (newborn baby of a woman with suspected or confirmed COVID-19

Birth

Table 3. Birth

Issue​ Consideration
Neonatal team attendance at birth The neonatal paediatric team should attend the birth as clinically required. 
Resuscitation
  • For anticipated complications requiring neonatal/paediatric support in the birth unit, every effort should be made to notify the neonatal/paediatric team as soon as possible and preferably at least 30 minutes prior to birth.

    This will enable the neonatal/paediatric team members to don appropriate PPE prior to entering the room.
  • Ideally, the team should be few in number, but highly experienced in neonatal advanced life support.
  • Minimise equipment open on the resuscitaire to essential items
  • Other items should be double bagged and available
  • Follow standard neonatal resuscitation and clinical assessment recommendations
 Reduce transmission risk The baby should be dried off and cleaned as soon as is reasonable after birth.

Post birth care

  • Isolation and infection prevention and control precautions must be implemented for the baby for at least 14 days, in the acute healthcare setting or at home. Consult with clinical microbiologist or infectious disease (ID) specialist on case by case basis.
  • Maintain high index of suspicion for signs of sepsis/unwell baby for all newborn babies of women with suspected or confirmed COVID-19 throughout their hospital stay, or period of special precautions at home.

Table 4. Well term newborn baby

Issue​ Consideration
Co-location
  • The well term newborn baby of a woman with suspected or confirmed COVID-19, who can care for her baby/babies, should be co-located with the mother in a single room  
  • When deciding suitability for co-location consider: the disease severity and likelihood for deterioration, maternal preference, psychological wellbeing, test results, local capacity, and other clinical criteria
  • Support establishment of breastfeeding where appropriate.
Separation
  • If the woman is too unwell or unable to care for her baby, consider the following options:
  • neonatal unit admission until plans for discharge are finalised or  
  • care on the postnatal ward in a single room by a suitable alternative primary caregiver who is not a close contact or a suspect for COVID19 until plans for discharge are finalised.
  • A daily risk assessment should take place to consider the ongoing suitability of the location for the baby, where separation from the mother is unavoidable
  • Support expressed breastmilk feeds to the baby if mother's clinical condition allows.
Reduce transmission risk Babies are at risk of infection from a woman's respiratory secretions after birth. The woman and support person who was present at birth should practice hand and respiratory hygiene and wear a face mask during feeding or other close mother-baby interactions including early skin to skin post birth, maintaining social distance of at least 1.5 metres.

Table 5. Newborn baby who requires admission to the neonatal unit (from the birth environment or postnatal ward)

Issue​ Consideration
Admission to the Neonatal Unit
  • Suspected or confirmed COVID-19 maternal infection is not itself an indication for the baby to be admitted to a neonatal unit
  • The usual local indications for admission criteria should be followed.
Location in the neonatal unit
  • Admitted babies should be cared for in closed incubators (humidicrib) and, when available, in a single room.
  • Where a single or separate room is not available, neonatal units where possible should identify 3 separate areas to cohort newborn infants:

1. Proven neonatal COVID-19.

2. Suspected neonatal COVID-19 (i.e. tests pending in woman and/or neonate)

3. No risk or suspicion of COVID-19

If necessary 1 and 2 could be combined with social distance, with a separate area for 3.

Parental access to baby
  • Women who have suspected or confirmed COVID 19 are NOT able to visit the neonatal unit until they are released from isolation or the baby is discharged to the mother. Consult with clinical microbiologist or infectious disease specialist on case by case basis to determine when this can occur.
  • During the time the woman and her partner are unable to visit the baby other methods of contact should be explored, including photos and video.
Transport
  • Where feasible, transport baby in a closed incubator between locations in the facility.
  • Plan the transport route in advance and consider use of a dedicated elevator/a runner to open doors and clear obstacles to ensure transfer is achieved with minimal contact with others.

Feeding choice for newborn babies born to women with suspected or confirmed COVID 19

Table 6.  Feeding Choice

Issue​ Consideration
Breastfeeding
  • Support maternal feeding preferences; encourage breastfeeding and expressing breast milk 
Expressing breastmilk
  • Further advice about breastfeeding and expressing can be found at https://www.health.nsw.gov.au/Infectious/alerts/Pages/coronavirus-faqs.aspx#2-suspected-confirmed-breastfeeding

Testing of newborn babies born to women with suspected or confirmed COVID 19

Table 7. Testing

Issue​ Consideration
Routine testing
  • Routine testing of asymptomatic newborn babies born to women with suspected or confirmed COVID-19 is not recommended.
  • Routine testing should not be used to determine the appropriate location and infection control precautions used.
Indications for testing
  • Testing is indicated if newborn infants are symptomatic within the minimum 14-day incubation period, in the acute healthcare setting or at home. Check with local pathology units on testing criteria for neonates.

Discharge Planning

Table 8.  Discharge planning for newborn infants born to women with suspected or confirmed COVID-19

Issue​ Consideration
Discharge Discharge should be considered when the woman and baby are well enough to go home. Discuss risks and benefits of close contact versus postnatal separation, particularly where the baby is ready for discharge home but the woman remains unwell.  In this case a suitable appropriate primary caregiver should be identified.
Discharge prior to 14 days Clinical monitoring of the baby should continue until at least 14 days after birth if born to a woman with suspected or confirmed COVID-19 or after symptoms develop.  Local capacity should determine the method of monitoring.  Telehealth and home visiting may be options.
Discharge planning
  • Care planning should be individualised 
  • Families should be included in the planning, and all the essentials of postnatal care should be considered
  • The family must be provided with information on post-discharge illness and have a plan in place for assessment and re-admission of mother or baby where required.

Document information​

Developed by
  • Health and Social Policy Branch (HSPB)
Consultation by
  • Maternity, Child and Family Health (HSPB)
Review date: At least fortnightly
Reviewed by
  • Clinical Lead, Community of Practice, Neonatal
  • Clinical Lead, Community of Practice, Maternity
  • Neonatal Working Group, Community of Practice
  • Clinical Excellence Commission (CEC)
For use by: NSW Health is recommending that this guidance is used by neonatal services, including postnatal wards
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Current as at: Friday 17 April 2020
Contact page owner: Health Protection NSW