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Background

This guidance is for NSW neonatal services and is focussed on care in the acute healthcare setting of newborn babies of women who are either (1) close contacts or (2) suspected, probable or confirmed cases of COVID-19.

This guidance is based on available evidence to date on COVID-19. The importance of uncertainty is acknowledged, and this guidance will be subject to change over the course of the pandemic as new evidence emerges. The guidance focuses on specific considerations for neonatal services relevant to the COVID-19 environment and does not provide detail on specific clinical procedures.

Concern about community transmission of COVID-19 and application of appropriate personal protective equipment (PPE) continues to be a key focus for the health system, with the safety of neonatal patients, their families and staff our priority. 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.

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, probable 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)

Recommended general principles of service provision during COVID-19

Babies of women who are not suspected, probable nor confirmed COVID-19 nor a close contact

These babies should receive usual care

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

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

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

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

Case definition and testing (mother)

For current case definitions refer to the CDNA National Guidelines for Public Health Units. For COVID-19 testing criteria and the NSW Ministry of Health website.

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 on resources for staff is 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 close contact of the mother. The baby requires precautions (not necessarily separation) in the acute healthcare setting or at home for a minimum of 14 days after birth. If 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.

A baby of a woman who is an asymptomatic close contact of a case of COVID-19 is a contact of a contact. The mother will be in isolation/quarantine for 14 days after the contact in the acute healthcare setting or at home, even when initial test results are negative. If the baby is co-located with the mother, the period of isolation for the baby must be determined on a case by case basis.

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).

The duration of isolation of a baby with potential symptoms of COVID-19 and who is tested should be assessed on an individual basis in consultation with clinical microbiologist or infectious disease (ID) physician.

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 who is a close contact or who has suspected, probable or confirmed COVID-19 and her baby/babies:

  • 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/support person and provide identification of an alternative 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, probable or confirmed COVID-19

Birth

Care of baby at birth

Neonatal team attendance at birth

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

Resuscitation

  • At birth the baby is either considered a contact of a contact, or a close contact (see Risk management). The choice of PPE for the resuscitation team should mirror that worn by the staff caring for the women (in the birth room or in the operating theatre) as resuscitation is likely to occur in close proximity. 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)
  • For anticipated complications requiring either neonatal or paediatric support at birth, every effort should be made to notify the appropriate team as soon as possible; preferably at least 30 minutes prior to the birth. This will enable the team members to don appropriate PPE prior to entering the room and prepare any additional notifications that may be required.
  • Ideally the team should be limited to essential staff and all members should be experienced in neonatal 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.
  • Comply with the NSW Safety Notice 006/20 ‘Use of Viral Filters for Respiratory Care in Neonates’.

Post birth care

IPC precautions must be implemented for the baby during the period of isolation in the acute healthcare setting or at home. Consult with clinical microbiologist or ID physician on a case by case basis.

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.

Well term newborn baby

Co-location

  • The well term baby of a woman who is considered a 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, consider the disease severity and likelihood for maternal deterioration, maternal preference, psychological wellbeing, test results, local capacity, and relevant clinical criteria.
  • See guidance on transport between ward areas. Refer to Newborn baby who requires admission to the neonatal unit (from the birth environment or postnatal ward)
  • Support establishment of breastfeeding where appropriate.

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 on the postnatal ward in a single room by a suitable alternative primary caregiver
  • Support expressed breastmilk feeds for the baby if 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)

Centralised neonatal care for babies of women who are in isolation because they are classified as a close contact, or have 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 units within their networks and describe processes for escalation in their operational plans when this is required.

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 in woman and/or neonate), babies who are close contacts
    3. No suspicion of COVID-19 (this includes babies who are contacts of contacts)
    4. If necessary 1 and 2 could be combined, with a separate area for 3.

The CEC recommends that bed spacing should be at least 4m in cohorted patients.

Parental access to baby

  • Women and/or partner/support person who are in isolation/quarantine because they are considered a close contact or have suspected, probable or confirmed COVID-19 are NOT able to visit their baby on the neonatal unit until they are released from isolation. Consult with clinical microbiologist or ID physician on case by case basis to determine when release from isolation can occur.
  • During the time the woman and her partner/support person are unable to visit the baby other methods of contact should be explored, including photos and video.
  • Where compassionate grounds exist, such as end of life care, special arrangements should be considered where possible for parental access, such as locating the baby in a negative pressure room with its own entrance. These arrangements must not compromise the safety of other neonatal patients and their parents.

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, probable 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, probable or confirmed COVID-19

Testing

Routine testing

  • Routine testing of asymptomatic babies of women who are close contacts or have suspected, probable or confirmed COVID-19 is not recommended, but may be directed by public health units
  • Routine testing should not be used to determine (1) the appropriate location for the baby and (2) infection control precautions to be used.

Indications for testing

  • Testing is currently indicated if babies become symptomatic in the acute healthcare setting or at home. Symptoms of neonatal COVID-19 may be respiratory or non-respiratory in nature. A high index of suspicion for illness in the baby should be maintained during any isolation period. Consult with clinical microbiologist or ID physician on a case by case basis regarding testing procedures.
  • All symptomatic babies on the neonatal unit should be isolated or placed in the ‘confirmed case’ location whilst awaiting test results and cared for using appropriate PPE.

Discharge planning

Discharge considerations

Discharge should be considered when the mother and baby are 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

Clinical monitoring of the baby should continue until at least the end of the isolation period. If the baby is co-located with the woman, the maximal 14- day incubation period for the baby would commence on the last day the woman is considered potentially or actually infectious, and therefore will be longer than 14 days after birth. Local capacity and individual circumstances should determine the method of monitoring. Telehealth and home visiting may be appropriate 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 the discharge plan should include assessment and potential re-admission pathways for mother or baby where required.

Re-admission of babies of women with suspected, probable 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 most likely to occur.

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.

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 close contact of the mother until the isolation period post birth is complete, or until the mother is released from isolation and the baby has completed the resulting isolation period, whichever is longer (Refer to Risk Assessment and Care Planning). Consult with clinical microbiologist or ID physician 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 woman 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 (below).
  • The baby must be re-admitted under the care of a neonatologist or paediatrician
  • 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 PICU

  • 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 COVID-19 is indicated
  • The mother cannot 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
  • 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

Clinical Lead, Neonatal Community of Practice.

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
  • Neonatal Working Group Community of Practice.

For use by

Neonatal services, including postnatal wards.


Current as at: Monday 5 July 2021
Contact page owner: Health Protection NSW