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Background

This guidance is based on available evidence to date on COVID-19 and continues to be reviewed as new evidence becomes available. The guidance focuses on specific considerations for neonatal services including postnatal wards in the COVID-19 environment. It does not provide detail on specific clinical procedures, staffing nor patient flow.

Neonatal services should monitor the COVID-19 risk level and respond according to the Clinical Excellence Commission (CEC)  COVID-19 Infection Prevention and Control Manual(Chapter 3 Response and Escalation Framework).  Authorisation for an escalation of risk should be based on direction from the Public Health Emergency Operations Centre (PHEOC) and the CEC.

Women who do not fit all the criteria for a suspected or confirmed case should be treated as low risk for COVID-19, noting that women residing in local government areas (LGAs) with high prevalence of COVID-19 may be subject to the Public Health Order of the day. This may include increased testing after consulting with local Prevention and Control and Infectious Diseases teams to determine management in local facilities.

Infection prevention and control (IPC) precautions must be followed for all aspects of clinical care. For information on IPC practices see the CEC document COVID-19 Infection Prevention and Control Manual.

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

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Recommended general principles for neonatal service provision during COVID-19

The mother and baby should be considered as a dyad at birth, with the focus being on the COVID-19 status of the mother. Clinicians should refer to the CDNA National Guidelines for Public Health Units for risk assessment protocols and case definitions to determine the woman's COVID-19 status. Women who do not fit the criteria for classification as a close contact, or a suspected, or confirmed case should receive usual care, including those women who may have been tested as part of increased testing availability.

All service provision should take into account additional considerations related to the current COVID-19 risk level, as defined in CEC COVID-19 Infection Prevention and Control Manual (Chapter 3: Response and Escalation Framework).

The principles of safe and evidence based neonatal care remain the same. The utmost priority are the immediate medical needs of the baby. Optimal care for the baby should not be delayed regardless of their COVID-19 status, the COVID-19 strain or whether the baby and family reside in an LGA with high prevalence of COVID-19. 

The duration of isolation requirements for a baby with possible COVID-19 should be assessed on an individual basis in consultation with local Infection Control Prevention and Control and Infectious Diseases teams.

Staff should acknowledge that isolation from their baby, family or children may be a trigger for some parents, including Aboriginal families and refugees. Staff will need to identify mothers and families that may require additional support on referral or early in the admission. Staff will need to partner quickly with appropriate local support, for example Aboriginal Liaison Officers, Aboriginal health workers, multicultural health staff, and social work. Staff should seek advice from clinical leads to ensure that the best plan for additional support is developed with local resources.

Whenever possible care should be provided in the community.  When a health problem is suspected in a baby at home there must be clear local guidance to ensure rapid referral and assessment. When conducting home visits, clinicians should refer to the CEC - COVID-19 IPAC, Chapter 8: Home Visits.

Recommended general principles of service provision during COVID-19

Babies of women who are NOT suspected, confirmed  COVID-19 or a primary close contact

These babies should receive usual care

Babies of women who are suspected or a confirmed case of COVID-19

Babies in this situation are considered close contacts. Refer to Risk management.

Babies of women who are primary contacts of a case of COVID-19

Babies in this situation are considered close contacts. Refer to Risk management.

Babies of mothers who are a casual or secondary close contact of a case of COVID-19

The mother's classification should be monitored, and the management of the dyad varied in response to an alteration in classification.

Case definition and testing (mother)

For current case definitions refer to the CDNA National Guidelines for Public Health Units. For COVID-19 testing criteria, refer tot he NSW Ministry of Health Self-isolation fact sheets.

Release from isolation (mother)

For information on release from isolation, refer to the NSW Health Self-isolation fact sheets.

Unintended consequences

Service redesign or changes to models of care need to be accompanied by a robust documented risk assessment process to ensure there are no unintended adverse consequences of such changes.

Infection Prevention and Control (IPC) practices

Healthcare facilities should ensure appropriate IPC practices for Maternity and Neonatal Services. Detailed guidance and resources for staff are available on CEC - COVID-19 IPC.

Risk management

Risk assessment and care planning

Risk assessment

A baby born to a woman with suspected, probable or confirmed COVID-19 is a primary  close contact . A mother and a well-baby should be encouraged to stay together in the immediate postpartum period. The baby and mother require ongoing precautions, preferably in the care of the mother or a participant in care for a minimum of 14 days after birth.

A baby of a mother who is an asymptomatic close contact of a case of COVID-19 is  classified as a secondary close contact. The mother will be in isolation for 14 days after the contact with the case. The isolation can be in the acute healthcare setting, community support accommodation or at home. The mother's isolation continues even when initial test results are negative. If the baby is co-located with the mother, the period of isolation for the baby, and related operational processes for local facilities, must be determined on a case-by-case basis in consultation with local Prevention and Control and Infectious Diseases teams.

When a mother and baby are separated (for example when the baby requires neonatal admission) a baby who is a primary close contact requires isolation and infection prevention and control precautions for 14 days after separation.

A baby who is a secondary contact does not require isolation in the neonatal unit but cannot be visited by a parent who is currently in isolation (see Testing of babies of women considered close contacts or those with suspected, or confirmed COVID-19 ).

When mother and baby are separated (when the baby requires neonatal admission for example) a baby who is a close contact requires isolation precautions for 14 days after separation. A baby who is a contact of a contact does not require isolation in the neonatal unit but cannot be visited by a parent in quarantine. Refer to Newborn baby who requires admission to the neonatal unit (from the birth environment or postnatal ward).

Care planning

It is recommended that the following specialities regularly  convene, review and document the plan for birth, postnatal care and discharge of an admitted or outpatient woman who is a close to birthing and who is either of a COVID-19 case, or has suspected or confirmed COVID-19:

  • obstetrics/midwifery
  • neonatology or paediatrics
  • clinical microbiologist/ID physician
  • IPC staff
  • social worker as required

This plan should involve shared decision making with the woman and her partner and family.

When available, there should be identification of a family member who may need to take responsibility as  primary caregiver of the baby.    

Care of newborn baby of a woman considered to be either a close contact or suspected or confirmed COVID-19

Birth

Care of baby at birth

Neonatal team attendance at birth

The neonatal/paediatric team should only attend the birth as clinically required.

Resuscitation

  • The PPE donned by the resuscitation team should be the same as that worn by the staff caring for the woman. A sign on the door of the room should alert anyone entering of the level of PPE required. More guidance can be found in the CEC Infection Prevention and Control Manual(Chapter 4: Personal protective equipment)
  • The resuscitation team should be notified, as early as possible, if and when they are anticipated to attend a birth, preferably at least 30 minutes prior to the birth. This will enable the team members to don appropriate PPE and escalate if required.
  • The team should be limited to essential staff.
  • Limit equipment open on the resuscitaire to essential items.
  • Other items should be double bagged and available.
  • Follow recommended standard neonatal resuscitation and clinical assessment. Comply with the NSW Safety Notice 006/20 ‘Use of Viral Filters for Respiratory Care in Neonates’.

Post birth care

Maintain high index of suspicion for signs of sepsis or illness for all newborn babies throughout their hospital stay, or during the period of isolation at home. Clinical signs of COVID-19 in a baby can be subtle and therefore regular observations should be performed.

Well term newborn baby

Co-location

  • The well term baby of a woman who is considered a primary close contact, or who has suspected, probable or confirmed COVID-19, should be co-located and isolated/ quarantined with the mother in a single room (with own bathroom), provided the mother is well enough to provide care.
  • When deciding suitability for co-location, the multidisciplinary team should consider factors including local capacity, clinical criteria, the mother's disease severity and likelihood for deterioration, maternal preference, and maternal psychological wellbeing. 
  • Consult with local Infection Prevention and Control and Infectious Diseases teams to determine management in local facilities.
  • When the baby is co-located with the mother, the 14 days isolation period for the baby commences on the last day the mother is considered infectious and therefore will be longer than the minimum 14 days after birth.

Separation

  • If the mother is too unwell or is unable to care for her baby, consider the following options:
    • neonatal unit admission until discharge planning is finalised or
    • care at home or by a suitable alternative carer at their residence
  • Support expressed breastmilk feeds for the baby if the mother’s clinical condition allows.

Reduce transmission risk

Babies are at risk of infection from the mother’s respiratory secretions after birth. The mother should practice hand and respiratory hygiene and wear a surgical face mask during feeding or other close mother-baby interactions. Between interactions the mother should maintain a physical distance of at least 1.5 metres from the baby.

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

Tiered perinatal networks should consider the capability of the neonatal units within their networks and describe processes for escalation in their operational plans. See:  NSW critical care management of neonatal patients.

Admission to the Neonatal Unit

  • Maternal COVID-19 infection is not itself an indication for the baby to be admitted to a neonatal unit
  • The usual local criteria for admission should be followed.

Location of baby in the neonatal unit

  • Babies who have been accommodation with the mother and later admitted to the neonatal unit (where the mother is a close contact or has suspected, probable or confirmed COVID-19) should be cared for in closed incubators (humidicribs) 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 babies based on:
    1. Confirmed neonatal COVID-19.
    2. Suspected neonatal COVID-19 (i.e. tests pending for mother and/or neonate), and babies who are primary close contacts
    3. No suspicion of COVID-19 including babies who are secondary close contacts.

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

The CEC recommends that bed spacing should be at least 1.4m in cohorted areas (or for cohorted patients).

Visiting

  • During periods of high transmission (RED ALERT), visitor (including children/siblings) restrictions should be based on risk assessment and individual patient needs and circumstances.
  • Parents who have been advised to isolate are not to visit the neonatal unit except for compassionate reasons.  Where compassionate grounds exist, such as end of life care, special arrangements should be considered for parent access. These arrangements must not compromise the safety of other patients nor their parents.
  • During the time the parents are unable to visit their baby explore other methods of contact, including photos, video and video conferencing.
  • The parents may, when it is supported by local guidance, nominate a person who is not a close contact or suspected or confirmed case of COVID-19 to visit their admitted baby.
  • Consult with local Infection Prevention and Control and Infectious Diseases teams to determine management in local facilities on a case by case basis to determine when release from isolation can occur.

Transport

  • Where feasible, babies should be transported in closed incubators between locations in the facility. Where a closed system is not available, an open cot can be used, but care should be taken to ensure the transfer time is kept to a minimum.
  • Plan the transport route in advance to minimise contact with others. Consider use of a dedicated elevator and a runner to open doors and clear obstacles.

Feeding choice for babies of women considered close contacts or those with suspected or confirmed COVID-19

Feeding choice

Breastfeeding

Support maternal feeding preferences; encourage breastfeeding and expressing breast milk.

Expressing breastmilk
The NSW Health website has further advice about breastfeeding and expressing and other Frequently asked questions.

Testing of babies of women considered close contacts or those with suspected or confirmed COVID-19

Routine testing of well and asymptomatic babies of women who are close contacts or have suspected or confirmed COVID-19 and are co-located with the mother is not recommended.

Indications for testing are:

  • Testing should only be done when it will influence management, patient safety, parent contact or has been requested by local Infection Prevention and Control and Infectious Diseases teams to manage cohort or exposure management. 
  • If there are other situations where for example, other family members are COVID-19 positive, swabbing of the neonate should be discussed with Infectious Disease and/or Infection Prevention and Control or the local Public Health Unit as appropriate.
  • After discharge: testing is currently decided case by case basis in consultation with local Infection Control and Infectious Diseases teams.  It is indicated if babies become symptomatic.

Testing

Maternal Status Baby Clinical Status Baby Location  Baby testing  Recommendations

 

 

 

COVID-19 positive
OR
Close contact, tests pending with likely delay to a result ​

Well and asymptomaticCo-located and isolated with the mother in a community or hospital settingRoutine testing not indicated
​Well and asymptomaticRequires assessment and/or admission to hospital (in a different location to the mother) for any reason​Recommended.

Timing of initial and any subsequent swabs should be discussed with the Infectious Diseases team.

Unwell or possible signs and symptoms of COVID-19Inspection of location

Recommended

Timing of initial and any subsequent swabs should be discussed with the Infectious Diseases team.

​Close contact with recent negative test

Unwell or possible signs and symptoms of COVID-19

 

Inspection of location

Consider. 

(and retest the mother)

Mother neither COVID positive/suspected or close contactRequires intra/inter hospital transfer for any reasonIrrespective of location

A local decision is often made by the accepting hospital.

If testing for baby is performed or requested prior to inter-hospital transfer, transfer should not be delayed pending results

 

Discharge planning

Testing prior to discharge

  • Testing of babies born to mothers who are neither COVID-19 positive or a close contact is not recommended.

Discharge considerations

  • Discharge should be considered when the mother or baby is well enough to go home.
  • Discuss the risks and benefits of close contact and postnatal separation. This is particularly important when the baby is ready for discharge home and the mother remains unwell. In this case a suitable appropriate primary caregiver may be necessary.

Discharge prior to 14 days/end of baby's isolation

  • Clinical monitoring of the baby should continue until at least the end of their isolation period. If the baby is co-located with the mother, the 14-day isolation period for the baby would commence on the last day the mother is considered potentially infectious, and therefore will be longer than 14 days after birth.
  • If other household members are positive, the baby’s 14-day incubation / isolation period starts on the day the last person in the household was released from isolation.
  • Local capacity and individual circumstances should determine the method of monitoring. Telehealth and home visiting may be appropriate options.
  • If review is required post discharge but prior to the end of the isolation period, appropriate PPE should be worn.

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.
  • The discharge plan should include assessment and potential re-admission pathways for mother or baby if required.

Re-admission of babies of women with suspected  or confirmed COVID-19

When a health problem is suspected in a baby at home there must be clear local guidance to ensure rapid referral and assessment. Although vigilance for COVID-19 is essential, it should be remembered that common newborn complications are the most likely explanation for presenting clinical conditions.

Initial triage should be undertaken by telephone to determine an appropriate location for the assessment. Where assessment at the facility is warranted the normal route of access at the facility should be through the emergency department, not through direct access to the postnatal ward or neonatal unit. Health workers should give clear instructions to the family about local attendance, and in all circumstances should wear appropriate PPE when providing care in line with the CEC  Infection Prevention and Control Manual (Chapter 4 Personal Protective Equipment).

Centralised neonatal care for babies of women with suspected, probable or confirmed COVID-19 is not recommended at this stage of the pandemic in Australia. Tiered perinatal networks should consider the capability of the neonatal and paediatric units within their network and describe processes for escalation in their operational plans for when his is required.

Tiered perinatal networks should consider the capabilities of their neonatal and paediatric units and describe processes for escalation in their local operational plans see  NSW critical care management of neonatal patients.

Principles for re-admission

Babies well enough not to warrant admission

  • Where possible, the baby should be managed at home
  • Close monitoring of the baby’s condition must continue according to local protocols
  • The baby should remain in isolation at home as a primary contact of the mother or other household members until the baby's isolation period is complete, and the baby has completed the resulting isolation period, whichever is longer (Refer to Risk Assessment and Care Planning). Consult with local Infection Control and Infectious Diseases teams to determine management  on case-by-case basis.

Babies requiring management as in-patient, but not requiring neonatal unit or paediatric intensive care unit (PICU) admission

  • The baby and mother should be co-located and isolated in a single room with own bathroom, preferably on the postnatal or paediatric ward. A risk assessment should be conducted to assess whether the mother is well enough to care for the baby. If local facilities do not allow adequate isolation of the mother with the baby, proceed as if the baby was admitted to the neonatal unit (Refer to Babies requiring management as in-patient on neonatal unit or paediatric intensive care unit).
  • All babies, including those < 10 days and/or those co-located with a carer, must be re-admitted under the care of a neonatologist or paediatrician.  Refer to  Clinical Determination for Boarder Baby Registration.
  • The mother and baby must continue to be isolated unless both have received clearance from a clinical microbiologist or ID physician to de-isolate. In the community, clearance to de-isolate will be directed by the local public health unit in line with NSW Health/CDNA guidelines for Public Health Unit guidelines.
  • Maternal feeding preferences should be supported.

Babies requiring management as in-patient on neonatal unit or paediatric intensive care unit

  • The baby must continue to be isolated on the neonatal unit as per local arrangements (refer to Newborn baby who requires admission to the neonatal unit (from the birth environment or postnatal ward) until de-isolation is assessed and agreed to on a case by case basis by clinical microbiology or ID physician
  • Consult with ID physician on a case-by-case basis to determine if testing for SARS-Cov-2 is indicated
  • Testing may be indicated if it changes management
  • Neither the mother nor her partner can visit the baby until she has received clearance from a clinical microbiologist or ID physician to de-isolate
  • The mother should be supported to express breastmilk for her baby if this is her preference.

Discharge planning

  • Local criteria for discharge should be followed
  • Information should be given to parents about monitoring and follow up, and how to seek advice if concerns arise
  • Closer monitoring should be provided after discharge as per local policy with additional monitoring for COVID-19 related symptoms
  • Isolation measures to continue as directed until clearance to de-isolate is received from a clinical microbiologist or ID physician.

Document information

Developed by

Health and Social Policy Branch (HSPB)

Consultation

Neonatal COVID-19 Working Group (currently supported by Agency for Clinical Innovation (ACI))

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.

Review date

Monthly or as required

Reviewed by

  • Clinical Lead, Community of Practice, Neonatal
  • Clinical Lead, Community of Practice, Maternity
  • Clinical Excellence Commission.

For use by

Neonatal services, including postnatal wards.


Current as at: Friday 15 October 2021
Contact page owner: Health Protection NSW