Approach to a Neonate Born to a COVID-19 Positive Mother

Introduction

The management of a neonate born to a mother with confirmed or suspected COVID-19 requires a balance between infection prevention and the promotion of physiological bonding and breastfeeding. Early in the pandemic, guidelines favored separation; however, evolving evidence has established that the risk of vertical transmission is low (approximately 3–8%) and that the benefits of rooming-in and breastfeeding outweigh the risks of horizontal transmission when appropriate precautions are taken. The approach involves meticulous delivery room care, infection control during postnatal stay, strategic testing, and vigilant monitoring for complications such as Multisystem Inflammatory Syndrome in Neonates (MIS-N).

1. Delivery Room Management

The primary goal in the delivery room is to facilitate safe transition while minimizing the risk of viral transmission to the neonate and healthcare workers (HCWs).

• Preparation and PPE: Personnel attending the delivery should wear full Personal Protective Equipment (PPE), including N95 masks, face shields, gowns, and gloves. The number of staff should be minimized to essential personnel only.
• Cord Clamping: Delayed Cord Clamping (DCC) is recommended for at least 60 seconds in vigorous term and preterm infants, provided the mother is stable. There is no evidence that DCC increases the risk of viral transmission.
• Skin-to-Skin Contact (SSC): Immediate SSC is encouraged for stable neonates to promote thermoregulation and bonding. The mother should wear a medical mask and practice hand hygiene before holding the baby.
• Resuscitation: If resuscitation is required, it should follow standard Neonatal Resuscitation Program (NRP) guidelines. Aerosol-generating procedures (AGPs) like suctioning, bag-mask ventilation, or intubation should be performed with strict adherence to airborne precautions. The resuscitation area should ideally be at least 6 feet away from the mother or in a separate room if feasible, though this is not strictly mandated if PPE is adequate.

2. Postnatal Care and Isolation Protocols

Current global and national guidelines (including MoHFW, NNF, and AAP) strongly advocate for keeping the mother and baby together (rooming-in) rather than routine separation.

• Rooming-In: Neonates should room-in with the mother to facilitate breastfeeding and bonding. The cot should be placed at a distance of at least 2 meters (6 feet) from the mother’s head when not feeding. Physical barriers such as curtains can be used if space is limited.
• Breastfeeding: The SARS-CoV-2 virus has not been conclusively found to be viable in breast milk. Exclusive breastfeeding is strongly recommended. Mothers must practice respiratory hygiene (wearing a triple-layer mask) and wash hands with soap and water for at least 20 seconds before and after touching the baby.
• Infection Prevention: If the mother is too ill to care for the baby, a healthy caregiver (who is COVID-negative and vaccinated) can provide care. If no caregiver is available, expressed breast milk should be provided.

3. Neonatal Testing Strategy

Testing is crucial to differentiate between vertical transmission (intrauterine), intrapartum transmission, and horizontal (postnatal) transmission.

• Timing of Test: A nucleic acid amplification test (RT-PCR) is the gold standard. Testing is generally recommended at 24 hours of life. If negative, or if testing capacity is limited, a repeat test may be done at 48 hours or prior to discharge.
• Sample Site: Nasopharyngeal or oropharyngeal swabs are preferred. Cord blood or placental testing is generally reserved for research purposes to document vertical transmission.
• Interpretation:
  • Positive at <24 hours: Suggests intrauterine or intrapartum transmission.
  • Negative at 24 hours but positive >48 hours: Suggests horizontal transmission from the mother or environment.
  • Persistent Positivity: Rarely, neonates may remain PCR positive for weeks, though infectivity usually declines.

4. Clinical Manifestations and Monitoring

The majority (>90%) of neonates born to COVID-19 positive mothers are asymptomatic. However, close monitoring is essential as clinical deterioration can occur.

• Asymptomatic Neonates: Require routine care with a focus on feeding adequacy, temperature stability, and perfusion.
• Symptomatic Neonates: Symptoms may mimic sepsis or respiratory distress syndrome (RDS). Common features include:
  • Respiratory: Tachypnea, grunting, nasal flaring, desaturations.
  • Gastrointestinal: Feeding intolerance, vomiting, diarrhea.
  • Systemic: Temperature instability (fever or hypothermia), lethargy, hypotonia.
  • Neurological: Irritability or seizures (rare).

Laboratory Evaluation for Symptomatic Infants:

• Baseline: Complete blood count (CBC) to look for lymphopenia or leukocytosis; C-reactive protein (CRP).
• Extended: If the infant is critically ill, evaluate for cytokine storm and coagulopathy: D-dimer, Ferritin, LDH, Procalcitonin, and Liver Function Tests.
• Cardiac: Troponin-I and NT-proBNP should be checked if there is hemodynamic instability to rule out myocardial dysfunction.

5. Management of Symptomatic Neonates

Management is primarily supportive, as no specific antiviral therapy is routinely approved for neonates.

• Respiratory Support:
  • Use non-invasive ventilation (CPAP/HFNC) as the first line for respiratory distress.
  • Use viral filters on expiratory limbs of respiratory circuits to protect HCWs.
  • Intubation and mechanical ventilation are reserved for severe respiratory failure (ARDS) or shock.
• Hemodynamic Support:
  • Fluid resuscitation for shock.
  • Inotropes (Epinephrine/Dobutamine) if there is evidence of myocardial dysfunction or hypotension.
• Therapeutics:
  • Antibiotics: Empirical antibiotics should be started pending blood culture results, as bacterial sepsis is a common mimic. They should be stopped if cultures are sterile and the clinical picture confirms COVID-19.
  • Corticosteroids: Not routinely recommended for acute neonatal COVID-19 unless the infant meets criteria for Multisystem Inflammatory Syndrome (MIS-N) or has specific indications (e.g., refractory shock).
  • Anticoagulation: Prophylactic anticoagulation is generally not recommended for neonates unless there is a confirmed thrombotic event or extremely high risk (e.g., central lines, severe coagulopathy).

6. Multisystem Inflammatory Syndrome in Neonates (MIS-N)

A small subset of neonates may present with MIS-N, a hyperinflammatory condition distinct from acute viral infection. This occurs secondary to the transplacental transfer of maternal antibodies (IgG) or neonatal antibody production.

• Definition: Onset of symptoms (fever, shock, multisystem involvement) in a neonate with evidence of SARS-CoV-2 antibodies (IgG positive, Antigen negative) and maternal history of infection.
• Key Features: Unlike older children with MIS-C, fever is present in only ~20–38% of MIS-N cases. Predominant features are cardiac dysfunction (arrhythmias, low ejection fraction), respiratory distress (PPHN), and coronary artery dilation.
• Management: Severe cases require immunomodulation with Intravenous Immunoglobulin (IVIG) (2 g/kg) and Corticosteroids (Methylprednisolone), often yielding rapid improvement.

7. Discharge and Follow-up

• Discharge Criteria: The neonate can be discharged when physiologically stable, feeding well, and gaining weight, regardless of the mother's isolation status, provided the family can ensure infection control at home.
• Vaccination: Routine birth doses (BCG, OPV, Hepatitis B) should be administered as per the immunization schedule prior to discharge.
• Follow-up:
  • Tele-consultation is preferred for minor concerns to reduce hospital visits.
  • Danger Signs: Parents must be counseled on danger signs: fast breathing, chest indrawing, poor feeding, lethargy, or temperature instability.
  • Post-COVID Sequelae: Infants with severe neonatal COVID-19 or MIS-N require follow-up Echocardiography (at 2–6 weeks) to monitor coronary arteries and ventricular function.