On this page

1. Background
2. Recommended general principles for neonatal service provision during COVID-19
3. Risk management
4. Testing of babies of women considered close contacts or with suspected or confirmed COVID-19
5. Care of a newborn baby of a woman considered to be either a close contact or confirmed COVID-19
6. Newborn baby who requires admission to the neonatal unit (from the birth environment, postnatal ward or home)
7. Feeding choice for babies of women considered close contacts or with suspected, or confirmed COVID-19
8. Discharge planning
9. Re-admission of babies of women with suspected or confirmed COVID-19
• Appendix 1:
• Flowchart for Isolation & testing requirements for inpatients in a neonatal unit
• Flowchart for Isolation & testing requirements for participants in care in a neonatal unit
10. Document information

Background

This guidance has been designed by clinicians and focuses on specific considerations for neonatal services, including postnatal wards, in the COVID-19 environment. Consider with local teams how various scenarios may work in your unit.

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).
• 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. access the most up to date information on the transmission risk in healthcare settings within NSW, via the Risk Monitoring Dashboard.

This guidance should be used with:

• COVID-19 Infection Prevention and Control Manual
• Communicable Disease Network of Australia (CDNA) Coronavirus Disease 2019
• (COVID-19) National Guidelines for Public Health Units
• Guidance for maternity services (NSW Health)
• Guidance on infant Feeding (NSW Health)
• National COVID-19 Clinical Evidence Taskforce
• Management of patient or visitor COVID19 exposures in healthcare facilities (CEC)
  
• Recommendations for COVID surveillance testing in NSW Healthcare facilities(CEC)
• COVID-19 Managing Health Worker Exposures and Return to Work in a Healthcare Setting (CEC)

Recommended general principles for neonatal service provision during COVID-19

The mother and baby should be considered as a dyad, with the focus being the COVID-19 status of the mother. Where possible, care should be provided to babies by the mother's bedside to avoid separating mothers and babies.

Recommended general principles of service provision during COVID-19

Risk management

The principles of safe and evidence based neonatal care remain the same. The priority is the immediate medical needs of the baby. Optimal care for the baby should not be delayed regardless of their mother's COVID-19 or her vaccination status.

Health workers should acknowledge that separation isolation from their baby, family or children may be a trigger for some parents, including Aboriginal families and refugees. Health workers will need to identify mothers and families that may require additional support on referral or early in the admission.

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 Infection Prevention and Control Manual (Chapter 8: Home Visits. Services should develop local guidance for the re-admission of babies, with suspected or confirmed COVID-19.

Risk assessment, isolation and care planning

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

It is not recommended to routinely test well and asymptomatic babies of mothers who are close contacts or have suspected or confirmed COVID-19 and are co-located with the mother.

Testing should only be done:

• when it will influence management, patient safety, parent contact or has been requested by local IPAC and Infectious Diseases teams
• if other family members are COVID-19 positive, swabbing of the neonate should be discussed with Infectious Disease and/or IPAC or the local Public Health Unit as appropriate
• after discharge if the baby becomes symptomatic.

Testing

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

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 health workers 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 health workers.
• Limit equipment open on the resuscitaire to essential items.
• Other items should be double bagged and available.
• 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 mother who is a close contact, or has suspected or confirmed COVID-19, should be co-located with the mother provided she is well enough to provide care.
• The baby is considered a close contact and should isolate as per the current public health order
• No testing is required unless admission to a neonatal unit is indicated. See information on testing.
• 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 as required.

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
• care at home or by a suitable alternative carer at their residence
• care on the postnatal or paediatric ward in a single room by a suitable primary caregiver.

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

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

Admission to the Neonatal Unit

• Maternal COVID-19 infection is not itself an indication for the baby to be admitted to a neonatal unit
• Where possible avoid separating mothers and babies.
• New models of clinical care delivery should be considered.

Location of baby in the neonatal unit

• Local units should develop an isolation plan that includes the availability of single rooms, cohorting of cases, separate areas and closed care systems (incubators).
• The CEC recommends that bed spacing should be at least 1.4m in cohorted areas (or for cohorted patients).

Visiting (see Appendix 1)

• Visiting restrictions should be based on COVID-19 transmission risk level via the Risk Monitoring Dashboard and individual family needs and circumstances.
• Participants in care should undertake a RAT at least every 3 days as per Recommendations for COVID surveillance testing in NSW Healthcare facilities
• Participants in care who are a COVID contact must follow the Self-isolation rules NSW Government
• visiting may occur with the following conditions
• daily RAT recommended prior to visiting for next 7 days
• must not congregate nor use areas shared with other parents (tea rooms, waiting areas etc.).
• monitor for symptoms and contact unit prior to visiting if symptions develop
• for compassionate reasons such as end of life care, special arrangements should be considered for family access.
• When parents are unable to visit their baby explore other methods of contact, including photos, telephone and virtual care.
• The parents may, when it is supported by local guidance, nominate a person to visit their baby.

Transport

• Where feasible, babies considered a close contact or a case, 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 with suspected, or confirmed COVID-19

Feeding choice

Breastfeeding

Support maternal feeding preferences. Encourage breastfeeding and expressing breast milk. Further advice for mothers about breastfeeding and expressing can be found at Guidance on infant feeding

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

Discuss the risks and benefits of being close to the mother and 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 monitoring of baby prior to end of isolation

• Local capacity and individual circumstances should determine the method of monitoring. Telehealth and home visiting may be appropriate options.
• If the baby is co-located with the mother, the isolation period for the baby would commence on the last day the mother is considered potentially infectious, and therefore will be longer than the mothers.
• If other household members are positive, the baby's isolation period starts on the day the last person in the household was released from isolation.

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 when required, face to face assessment. It should be remembered that common newborn complications are the most likely explanation for presenting clinical conditions.

Triage should be undertaken by telephone to determine an appropriate location for the assessment. Local guidance for location of assessment should be developed as per local capacity and clinical situation.

Unplanned access to the facility should be through the emergency department, not through direct access to the postnatal ward or neonatal unit.

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 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 as per local guidelines. A risk assessment should be conducted to decide whether the mother or her partner are well enough to care for the baby.
• Babies co-located with a carer, must be re-admitted under the care of a neonatologist or paediatrician. See Clinical Determination for Boarder Baby Registration.
• De-isolation will be in line with current public health orders and NSW Health COVID-19 self-isolation guidance

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
• Monitoring should be provided after discharge as per local policy with additional monitoring for COVID-19 related symptoms.

Appendix 1

Flowchart for isolation and testing requirement for neonatal units

^# To calculate the isolation period, day 0 is the day the case took their first positive test day 1 is the first full day after the first positive test was taken

⁺ To calculate the isolation period, day 0 is the first day since they last had contact with a COVID-19 case (birth is consid-ered a transmission event)

^* Isolation period must continue for 7 whole days despite negative PCR when symptoms are present.

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Flowchart for isolation and testing requirements for participants in care in a neonatal unit participants

General visiting principles

• undertake RAT every 3 days
• wear a surgical mask
• avoid congregating in shared areas
• monitor for symptoms & contact unit prior to visiting if symptoms develop.

*Must have remained asymptomatic for 72 hours prior to visiting

⁺PCR confirmed COVID disease does not require RATmonitoring for 30 days after being allowed to visit

^#To calculate the isolation period, day 0 is the first daysince they last had contact with a COVID-19 case.

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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

March 2022

Reviewed by

Clinical Lead, Neonatal Community of Practice

For use by

Neonatal services, including postnatal wards.