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Summary of published Chinese recommendations for perinatal management of SARS-CoV-2 infectionTestingSARS-CoV-2 specific testingRT-PCRSource of sample: upper respiratory tract (nasopharyngeal and oropharyngeal swabs), lower respiratory tract (sputum, trachea aspirate, bronchoalveolar lavage), blood, rectal swab/stool, urineMost commonly used are nasopharyngeal/oropharyngeal swabs and rectal swabsTime for testing of newborn: after 24 hours lifeViral genome sequencing from respiratory, rectal swabs, blood or urine specimens highly homologous to that of the known SARS-CoV-2Diagnosis of neonatal COVID-19Epidemiological historyMother with history of SARS-CoV-2 infection 14 days prior to delivery or within 28 days of deliveryContact history with other caregiver with known SARS-CoV-2 infection regardless of having symptoms or notNewborns with suspected infectionNewborns with the above epidemiological historyAcute respiratory illness with chest imaging consistent with SARS-CoV-2 pneumonia and unable to explain by other common etiologyNewborns with confirmed infectionAny positive RT-PCR testing. Mainly by positive RT-PCR testing of oropharyngeal/nasopharyngeal swabs or rectal swabs. Antibody testing recently become available and may be utilized to confirm the infectionDelivery room management for newborns born to mothers with confirmed or suspected COVIDMother SuspectedConfirmedSite of deliveryDeliver in designated treatment center if possible; preferably in negative pressure delivery room or OR OB notify NeoAt least 30 min prior to deliveryStaff PPELevel 2Level 3 if in mother’s delivery room Delayed cord clamping/ cord milkingNot recommendedAdmission of the neonateNeonatal observation room room-in/discharge with mom if maternal testing neg x2 or admit to isolation floor if maternal testing pos. NB isolation floor Duration of neonatal observation/isolationAt least 14 days unless maternal infection is ruled outAt least 14 daysTransportTransport of newborns born to mothers with suspected/confirmed infection from delivery room to observation floor/NICUTransport all neonates in isolettePlan for dedicated transport route and elevatorTerminal disinfection of isolette and transport route after transfer Transport of newborns with COVID-19Neonates confirmed to have COVID-19 should be transferred to designated pediatric COVID-19 treatment centerHospital should request the transport to the local health authority that will coordinate the transport. The neonates should be transported by a dedicated neonatal transport team that are equipped with all necessary neonatal transport equipment and PPEAmbulance for transporting COVID-19 patients: negative pressure ambulance (-10~-30Pa, air exchange 20times/hr, rate of filtration 99%)Transport team wear level 3 PPEGood communication between the staffs of sending and receiving hospital including contact history of parents and other care giversAllow one family member on the ambulance if that person passes the screeningScreening for family members: fill out a screening questionnaire and measure temperature. Both the family member being screened and the screening HCW will sign the questionnaire. Content of the questionnaire: travel and contact history of the recent 2 weeks, any fever or respiratory symptoms within the recent 2 weeks.Transport team follow pre-defined route and elevator to the isolation unit at the receiving hospitalTransport ambulance and equipment go through terminal disinfection post transportReceiving hospital fill out report cards to health authority regarding admission of COVID-19 patientsBreast feeding/breast milk feedingCurrent evidence is not enough to rule out the potential of SARS-CoV-2 excretion in the breast milk. No breast feeding or breast milk feeding if mom is suspected or diagnosed with COVIID-19, but pumping to establish and maintain milk supply is encouragedBreast feeding/breast milk feeding can resume if mother’s infection is ruled outInfected mom can resume breast feeding/breast milk feeding after she is considered curedDonor breast milk can be used, but there are two recommended approaches(from three documents):Donor milk can be used after pasteurization4,5;Donor milk should be screened first since the milk maybe donated by COVID-19 patients in the incubation period before they knew about the infection3Medical managementPrinciples of neonatal management: All suspected or confirmed cases need to be isolated and monitored as soon as possibleEffective single room isolation is most idealProvide close monitoring and supportive careStaff ProtectionPerform contact and droplet precaution, add air precaution when performing procedures with aerosol splashing risk, when caring for infants with suspected infectionWear level 3 PPE when getting into rooms/areas for confirmed cases. MonitoringMonitor changes in vital signs, ins & outPeriodic check of CBC, electrolytes, blood gas, coags, metabolic panel, and chest imaging as neededNeonatal floor or NICU set upSet up dedicated isolation ward or NICU for COVID-19 suspected/confirmed neonates or subdivide the NICU into transitional, quarantine and general patient care areas. Transitional and quarantine area should be separated from general patient care areas with a different path. All patients with suspected or confirmed infection should be placed in his/her own isolette.The goals of this set up are to prevent the spread of this infection in the NICU; protect the suspected but not infected neonates from getting the infection.Confirmed COVID-19 casesPlace in isolation rooms outside the regular NICU or neonatal floor, with its own pathPlace in negative pressure isolation rooms if availableCan place multiple positive babies in the same roomSuspected casesInfants born to mothers with suspected infection should be placed in single isolation rooms until maternal COVID is ruled outInfants born to mothers with confirmed infection should be placed in single isolation rooms and testing for SARS-CoV-2 sent after 24 hours of lifeInfants admitted from community with clear contact history and symptoms should be placed in single isolation rooms until at two RT-PCR testing (24 hours apart) are negativeInfants admitted from community with fever and/or respiratory illness without a clear COVID-10 contact history can be placed in the transition area with contact and droplet precautions and SARS-CoV-2 RT-PCR testing sentAntimicrobial treatmentSafety and efficacy of the antiviral medications used in the adult patients are not established in the neonatal population. Do not use antibiotics unless there is clear evidence of bacterial infectionManagement of severe COVID-19 Severe ARDS with “white lungs” and severe hypoxemia: consider surfactant, iNO and high frequency ventilationLow dose of steroids may be considered in selected cases with rapid progression of disease (proper doses not clear)IVIG can be considered in severe cases, 2g／kg divided by 2-5 timesCRRT and/or ECMO should be used in critically ill patients when indicatedSerum from patients in the convalescent phase of disease is being tried in adult patients and so far no data available for pediatricsDischarge criteriaAfebrile x3 days with improvement in clinical symptomsSignificant improvement of acute infiltrates on chest imagingRT-PCT testing negative x2 ( at least 24 hours apart)Post discharge managementContinued home self-isolation and monitoring for 14 daysHome visits by local health team if availableFollow up at 2 and 4 weeks post dischargeInstruction for home disinfectionKeep home well ventilated and newborn’s clothes and utensils should be cleaned separately from that of the adults’Use dedicated trash can with a plastic lining for the disposal of diaper and wipes. Spray or soak the content with disinfectant containing 500-1000mg/L effective chlorine and tighten the plastic bag before disposal. Surface, crib and floor: wipe or mop with disinfectant containing 250-500 mg/L effective chlorine and then again with clean water Linens and clothes: Soak with disinfectant containing 250-500 mg/L effective chlorine for 1 hour or boil for 15 minutes before regular washingHeat resistant bottles, pacifiers and other utensils: boil for 15 minutesReference:Chinese Neonatologist Association. Proposed prevention and control of 2019 novel coronavirus infection in neonates. Clin J Perina Med. Feb 2020, 23 (2):80-84Zheng C, Du L, Fu J et al. Emergency plan for inter-hospital transfer of newborns with SARS-CoV-2 infection. Chin J Comtemp Pediatr 2020, 22(3): 226-230 Doi:10.7499/j.issn.1008-8830.2020.03.009Wang L, Shi Y, Xiao T, et al. Chinese expert consensus on the perinatal and neonatal management for the prevention and control of the 2019 novel coronavirus infection (First edition) Ann Transl Med 2020;8(3):47Medical Association of Chinese People's Liberation Army. Response plans in the neonatal intensive care unit during epidemic of SARS-CoV-2 infection (2nd Edition). Chin J Contemp Pediatr, 2020, 22(3): 205-210Working Group for the Prevention and Control of Neonatal 2019-nCoV Infection in the Perinatal Period of the Editorial Committee of Chinese Journal of Contemporary Pediatrics. Perinatal and neonatal management plan for prevention and control of 2019 novel coronavirus infection (1st Edition). Chin J Contemp Pediatr, 2020, 22(2): 87-90Lu Q, Shi Y. Coronavirus diseas (COVID-19) and neonate: What neonatologist need to know. J Med Virol. 2020 Mar 1. doi: 10.1002/jmv.25740Zhu H, Peng S, Li H, Cheng Y, Wang H, and Xia S. Common issues and solutions in the management of novel coronavirus infection in high-risk neonates. Zhonghua Er Ke Za Zhi. Feb 28, 2020. DOI：10.3760/cma.j.issn.2096-2932.2020.02.001 ................
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