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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:

This guidance should be used with:

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

Issue Consideration
Babies co-located with their mother who are close contacts with no symptoms of COVID-19

These babies are considered close contacts.

Refer to Risk Management.

Babies of mothers who are a suspected or a confirmed case of COVID-19 These babies 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.

Being a close contact requires ongoing consideration of testing and isolation. Please also refer to Self-isolation rules | NSW Government

Discharge home prior to the end of baby's isolation period

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.

Infection Prevention and Control (IPAC) practices Healthcare facilities should ensure appropriate IPC practices for Maternity and Neonatal Services. Detailed guidance and resources for health workers are available on CEC - COVID-19 IPC.
Isolation period of babies co-located with their motherThe isolation period for the baby will commence on the last day the mother is considered potentially infectious, and therefore will be longer than the mother's.
Rapid Antigen Testing (RAT)Not recommended for use in neonates. PCR is the preferred testing option.
Release from isolation (mother)For information on release from isolation, refer to the Self-isolation rules NSW Government
Virtual careTo maintain contact with families in isolation consider virtual care.
Visiting - Participants in care (parents) not a case or close contact

Participants in care (parents) are to undertake a RAT every 3 days as per Recommendations for COVID surveillance testing in NSW Healthcare facilities

Refer to visiting guidance and Appendix 1

Visiting – Participants in care (parents) who are a suspected or confirmed COVID-19 or a close contact

May visit after meeting the criteria for release from isolation as per NSW Health COVID-19 self-isolation guidance

Refer to visiting guidance and Appendix 1

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

Issue Consideration
Risk Assessment

A baby may be a close contact because of exposure to a COVID positive parent or healthcare worker or may be considered a close contact if their mother is also a close contact.

If exposure has occurred as a result of contact with a positive health care worker refer to the Management of patient or visitor COVID19 exposures in healthcare facilities matrix.

Isolation in Neonatal Units

(see Appendix 1)

Inpatients in neonatal units who are:

  • Close contact
    • Require isolation for 7 days with nasal swab PCR on day prior to release from isolation
    • If negative – remove from isolation
    • If positive – classify as a case and manage accordingly
  • Confirmed case
    • isolation for 10 days from the first positive test or identification of symptoms
    • if symptoms persist on day 10, discuss with local ID physician on further plan

Participants in care (parents) of babies must isolate as per current public health orders and NSW Health COVID-19 self-isolation guidance

Care Planning

It is recommended that the specialities regularly convene, review, and document the plan for birth, postnatal care, and discharge with involvement of the woman, her partner and family.

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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

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 asymptomatic Co-located and isolated with the mother in a community or hospital setting Testing not indicated
​COVID-19 positive or close contact, tests pending with likely delay to a result Well and asymptomatic Requires assessment and/or admission to hospital (in a different location to the mother) for any reason Recommended - on day prior to release from isolation
​COVID-19 positive or close contact, tests pending with likely delay to a result Unwell or possible signs and symptoms of COVID-19 Irrespective of location Recommended
Close contact with recent negative test Unwell or possible signs and symptoms of COVID-19 Irrespective of location Consider (and retest the mother)
Mother neither COVID positive/suspected or close contact Requires intra/inter hospital transfer for any reason Irrespective 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.
Mother neither COVID positive/suspected or close contact Has had contact with positive Health worker. Risk classified as

Moderate or High

Inpatient settingTest on day 2 and day 6 post exposure

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

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

Newborns - for close contacts isolate or cohort for 7 whole days. 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). Monitor for symptoms. Do a PCR test when symptomatic (Isolation period must continue for 7 whole days despite negative PCR when symptoms are present.); when no symptoms on day 2 and day before release from isolation. If negative, De-isolate and monitor for symptoms for next 7 days. If positive or a confirmed case: Isolate or cohort for 10 whole days. 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. Monitor for symptoms. If asymptomatic after isolation period, deisolate. If symptoms persist on day 10, discuss with local ID physician for further plan.

# 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

For participants in care (e.g. parents/carers) who are close contacts, test and isolate for 7 whole days (*Must have remained asymptomatic for 72 hours prior to visiting). RAT on day before release from isolation, If negative - de-isolate and monitor for symptoms for next 7 days. Daily RAT recommended prior to visiting for next 7 days. If positive, or a confirmed case, isolate and no visiting for a minimum of 10 days. To calculate the isolation period, day 0 is the first daysince they last had contact with a COVID-19 case. Monitor for symptoms, if asymptomatic they may visit after 10 days. No testing required*=, They must have remained asymptomatic for 72 hours prior to visiting,  and PCR confirmed COVID disease does not require RAT monitoring for 30 days after being allowed to visit. If symptomatic continue to monitor and remain in isolation until asymptomatic.

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.


Current as at: Tuesday 15 March 2022
Contact page owner: Health Protection NSW