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4428490-52387500COVID-19?CLINICAL GUIDELINES????SUBJECT: GUIDELINES FOR MANAGEMENT OF INFANT BORN TO MOTHER WITH COVID19SCOPE: Sinai Hospital of Baltimore, Northwest Hospital, Grace?Medical Center and Carroll Hospital adopt the following guidelines for clinical services provided during the COVID-19 pandemic.????APPROVED BY:?Inpatient COVID19 Taskforce????APPROVAL DATE:?8/25/20;?LAST REVIEW DATE:????BACKGROUND: The following outlines considerations for newborn care after birth to a woman with suspected or confirmed COVID-19. DEFINITIONS:SARS-CoV-2: coronavirus that causes COVID-19COVID-19: symptomatic respiratory illness caused by the SARS-CoV-2 coronavirusEnhanced Droplet Precautions: patient care with use of the following:non-sterile glovesgownstandard surgical face maskeye protectioneye protection may take the form of goggles in combination with standard surgical face mask, or use of combined face mask/eye shieldpersonal eye glasses or contact lenses are not adequate eye protectionAirborne Precautions: patient care with use of all of the elements of Enhanced Droplet Precautions in combination with Respiratory Protection:N95 respirator mask or personal powered air respirators (PAPR) device replaces the standard procedural face maskGoggles must be used with N95 respirators for eye protection. PAPRs provide eye protectionSee below for the use of negative air pressure isolationAirborne Transmission: defined as respiratory pathogens transmitted by aerosolized droplets that remain suspended in the air. This type of transmission means that the pathogen can be acquired from breathing the same air as the patient; this can be the case for periods of time after the patient has left a room/area. Measles, varicella and tuberculosis are examples of respiratory infections that require Airborne Precautions which include use of respiratory protection and isolation in a room with negative air pressure. Current evidence supports transmission of SARS-CoV-2 by respiratory droplet and possibly by airborne transmission. Despite this, when available, isolation rooms with negative air pressure should optimally be used for the care of patients with confirmed COVID-19. As such rooms may be limited or unavailable at many centers, they should be reserved for patients with COVID-19 who require respiratory procedures or supports (e.g., invasive suctioning, nebulizer treatments, CPAP, mechanical ventilation) that may result in mechanical aerosolization of respiratory secretions.GUIDELINES:Newborn RiskIt remains unclear if SARS-CoV-2 is vertically transmitted from mother to fetus antenatally via maternal viremia and transplacental transfer. Prior published experience with respiratory viruses would suggest this is unlikely.Perinatal exposure may be possible at the time of vaginal delivery based on the detection of virus in stool and urine. Newborns are at risk of infection from a symptomatic mother’s respiratory secretions after birth, regardless of delivery mode All infants follow-up with PCP to make aware of mother’s COVID statusEvidence now suggests risk of newborn acquiring infection during the birth hospitalization is low when precautions are taken to protect newborns from maternal infectious respiratory secretionsMothers & newborns may room-in togetherDuring the birth hospitalization, the mother should maintain a reasonable distance from her infant when possible. When mother provides hands-on care to her newborn, she should wear a mask and perform hand-hygiene. Use of an isolette may facilitate distancing and provide the infant an added measure of protection from respiratory droplets.Non-infected partners or other family members should use masks and hand hygiene when providing hands-on care to the infant during hospitalization.Mother who is acutely ill with COVID-19 may not be able to care for infant in safe way. This situation may be appropriate to temporarily separate mother and newborn.Infant should be bathed as soon as is reasonably possible after birth, unless baby is delivered by C-Section with intact membranes.Newborns will be tested for perinatal viral acquisition as follows:molecular assay testing will be done by obtaining a single swab of the nasopharynx; or a single swab of the throat followed by the nasopharynx; or two separate swabs from each of these sites, and submit for a single test no earlier than 24 hours of age to facilitate detection of viral replicationThis testing is essential if mother has COVID, but not necessary if she is deemed recovered by clinical and laboratory picture before testing is due.For infants who are positive on their initial testing, follow-up testing at 48-72 hour intervals until two consecutive negative tests are obtained to establish that the infants has cleared the virus from mucosal sites.All infant’s primary care provider should be made aware of the mother’s COVID status.Delivery Room ManagementInitial stabilization/resuscitation of the newborn will take place as per center usual careNewborn resuscitation should not be compromised to facilitate maternal/infant separationIf the center has a newborn resuscitation room separate from the mother’s delivery room, this should be utilizedBecause of the uncertain nature of newborn resuscitation (that is, suctioning and/or tracheal intubation may be required), Airborne Precautions should be usedAdmissionInfants who are well-appearing at birth and who would otherwise be admitted to the center’s well newborn area should be cared for in a designated area separate from other newborns. Centers should assess their local structures to determine where such infants should receive care.Staff will use Enhanced Droplet Precautions for these infants Infants who require NICU care due to illness or gestational age at birth should be admitted to a single patient isolation room within the NICU If the infant requires technical CPAP, HFNC as CPAP, or any form of mechanical ventilation, Airborne Precautions must be used, until infection status is determined as outlined above. Breastfeeding Mother may breastfeed with a mask and/or express breast milk (after appropriate hand hygiene) and this milk may be fed to the infant. Breast pumps and components should be thoroughly cleaned in between pumping sessions using standard policies (clean pump with antiseptic wipes; clean pump attachments with hot soapy water)VisitationNo visitation will be allowed until the newborn’s infection status is determinedException: the non-maternal parent (or designated equivalent) may visit the infant and participate in care if they are asymptomatic and/or it has been 10 days since they have had COVID-19 symptoms improve, even if they are being monitored for infection due to exposure to the mother. This person will use Enhanced Droplet Precautions during visits.If the newborn is uninfected but requires prolonged hospital care for any reason, the mother will not be allowed to visit the infant until she meets the CDC recommendations: Resolution of fever for 24 hrs, without use of antipyretic medication and other COVID-19 symptoms have improvedAt least 10 days have passed since symptoms appeared or 10 days have passed since the date of the test of the asymptomatic mom who tested COVID +A mother who was critically ill (i.e., ICU Admission) with COVID-19 may visit after 20 days after symptoms have improvedIf a mom wishes to obtain two Negative assay for COVID-19 from at least two consecutive sets of paired nasopharyngeal and throat swabs specimens collected ≥24 hours apart because it may allow her to visit her baby sooner, she may do so. DischargeConsiderations when infant is medically appropriate for dischargeInfants determined to be infected, but with no symptoms of COVID-19, may be discharged home with appropriate precautions and plans for outpatient follow-up on a case-by-case basis.Infants whose infection status has determined to be negative will be optimally discharged home when otherwise medically appropriate, to a designated healthy caregiver who is not under observation for COVID-19 risk. If such a caregiver is not available, manage on a case-by-case basis.Education for families in the home environment should include:Mother should use a mask and hand-hygiene when directly caring for the infant, until she has been afebrile for 24 hourrs without use of antipyretics, at least 10 days have passed since the positive test, and symptoms have improved.Other caregivers in the home should use masks and hand hygiene before and after contact with the infant until their status is resolved. ................
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