Managing a tertiary-level NICU in the time of COVID-19: Lessons learned from a high-risk zone

Making respiratory care safe for neonatal and paediatric intensive care unit staff: mitigation strategies and use of filters

Background

Many medical devices in pediatric and newborn intensive care units can potentially expose healthcare workers (HCWs) and others to transmission of respiratory and other viruses and bacteria. Such fomites include ventilators, nebulizers, and monitoring equipment.

Approach

We report the general, novel approach we have taken to identify and mitigate these risks and to protect HCWs, visitors and patients from exposure while maintaining the optimal performance of such respiratory equipment.

Findings

The approach combined a high level of personal protective equipment (PPE), strict hand hygiene, air filtration and air conditioning and other relevant viral risk mitigation guidelines. This report describes the experiences from the SARS-CoV-2 pandemic to provide a reference framework that can be applied generally. The steps we took consisted of auditing our equipment and processes to identify risk through sources of potentially contaminated gas that may contain aerosolized virus, seeking advice and liaising with suppliers/manufacturers, devising mitigation strategies using indirect and direct approaches (largely filtering), performing tests on equipment to verify proper function and the absence of negative impacts and the development and implementation of relevant procedures and practices. We had a multidisciplinary team to guide the process. We monitored daily for hospital-acquired infections among staff caring for SARS-CoV-2 patients.

Conclusion

Our approach was successful as we have continued to offer optimal intensive care to our patients, and we did not find any healthcare worker who was infected through the course of caring for patients at the bedside. The lessons learnt will be of benefit to future local outbreaks or pandemics.

Psychosocial Difficulties Experienced By Parents Of Babies Treated In A Neonatal Intensive Care Unit During The Coronavirus Pandemic

AIM

This study had two objectives: (1) to investigate the psychosocial difficulties experienced by parents of babies treated in a neonatal intensive care unit during the coronavirus pandemic and (2) to determine parent-infant attachment.

MATERIALS AND METHODS

This study adopted phenomenology, a qualitative research design in order to answer the research questions design. The sample consisted of 20 parents of babies treated in the neonatal intensive care unit (NICU) of a City Hospital in Turkey between July and August 2021. Participation was voluntary. Data were collected using a sociodemographic characteristics questionnaire and a semi-structured qualitative interview form. Each participant was interviewed face to face. Each interview was recorded and transcribed. The data were analyzed using content analysis.

RESULTS

Participants had a mean age of 32.2 ± 3.61 years and at least secondary school degrees. Babies were admitted to the NICU for congenital anomalies (n = 3) or preterm birth (n = 7). Participants experienced anxiety, worry, and loneliness and produced less milk because they could not see and touch their babies. Their greatest source of support was their spouses.

CONCLUSION

Parents of babies treated in the NICU during the COVID-19 pandemic experience anxiety, sadness, unhappiness, and loneliness. The preventive measures against the pandemic affect parents psychosocially. Healthcare professionals should plan and implement care practices and establish effective communication with parents to identify their physiological, psychological, and social needs and help them produce breastmilk and bond with their babies.

Adapting obstetric and neonatal services during the COVID-19 pandemic: a scoping review

BACKGROUND

The provision of care to pregnant persons and neonates must continue through pandemics. To maintain quality of care, while minimizing physical contact during the Severe Acute Respiratory Syndrome-related Coronavirus-2 (SARS-CoV2) pandemic, hospitals and international organizations issued recommendations on maternity and neonatal care delivery and restructuring of clinical and academic services. Early in the pandemic, recommendations relied on expert opinion, and offered a one-size-fits-all set of guidelines. Our aim was to examine these recommendations and provide the rationale and context to guide clinicians, administrators, educators, and researchers, on how to adapt maternity and neonatal services during the pandemic, regardless of jurisdiction.

METHOD

Our initial database search used Medical subject headings and free-text search terms related to coronavirus infections, pregnancy and neonatology, and summarized relevant recommendations from international society guidelines. Subsequent targeted searches to December 30, 2020, included relevant publications in general medical and obstetric journals, and updated society recommendations.

RESULTS

We identified 846 titles and abstracts, of which 105 English-language publications fulfilled eligibility criteria and were included in our study. A multidisciplinary team representing clinicians from various disciplines, academics, administrators and training program directors critically appraised the literature to collate recommendations by multiple jurisdictions, including a quaternary care Canadian hospital, to provide context and rationale for viable options.

INTERPRETATION

There are different schools of thought regarding effective practices in obstetric and neonatal services. Our critical review presents the rationale to effectively modify services, based on the phase of the pandemic, the prevalence of infection in the population, and resource availability.

Italian neonatologists and SARS-CoV-2: lessons learned to face coming new waves

The aim of this review was threefold: (a) to retrieve all SARS-CoV-2 evidences published by Italian neonatologists working in maternity centers and NICUs during the pandemic; (b) to summarize current evidence for the management of term and preterm infants with a SARS-CoV-2-related illness; and (c) to provide an update for dealing with the second wave of COVID-19 and discuss open questions. A review was conducted using MEDLINE/PubMed and the national COVID-19 registry of the Italian Society of Neonatology including citations from December 1, 2019 to October 28, 2020. Sixty-three articles were included. Collected data were divided into the following topics: (a) antenatal management, (b) management in delivery room, (c) postnatal management, (d) mother-baby dyad and breastfeeding management, (e) neonatal emergency transport system reorganization, (f) parents' management and perspective during SARS-CoV-2 pandemic, and (g) future perspective. Evidences have evolved over the pandemic period and the current review can be useful in the management of the mother-neonate dyad during SARS-CoV-2 future waves. Italian neonatologists have played an active role in producing official guidelines and reporting data that have contributed to improve the care of neonates. A joint European action plan is mandatory to face COVID-19 in neonates with more awareness. IMPACT: A joint European action plan is mandatory to face COVID-19 in neonates with more awareness. This review summarizes the available evidences from neonatal COVID-19 management in Italy analyzing all the published paper in this specific field of interest. The current review can be useful in the management of the mother-neonate dyad during the SARS-CoV-2 future waves.

Impact of the COVID-19 pandemic on developmental care practices for infants born preterm

OBJECTIVES

To assess the impact of the COVID-19 pandemic on rates of hospital visitation and rates and durations of developmental care practices for infants born preterm.

METHODS

We analyzed electronic medical record data from 129 infants born at less than 32 weeks gestational age (GA) cared for in the Lucile Packard Children's Hospital neonatal intensive care unit (NICU) in a COVID-19-affected period (March 8, 2020 to Nov 30, 2020, n = 67) and the analogous period in 2019 (n = 62). Rates of family visitation and of family- and clinical staff-delivered developmental care were compared across cohorts, adjusting for covariates.

RESULTS

Families of infants visited the hospital at nearly half of the rate during 2020 as during 2019 (p = 0.001). Infants experienced developmental care less frequently in 2020 vs. 2019 (3.0 vs. 4.3 activities per day; p = 0.001), resulting in fewer minutes per day (77.5 vs. 130.0; p = 0.001). In 2020, developmental care activities were 5 min shorter, on average, than in 2019, p = 0.001. Similar reductions occurred in both family- and staff-delivered developmental care. Follow-up analyses indicated that effects persisted and even worsened as the pandemic continued through fall 2020, despite relaxation of hospital visitation policies.

CONCLUSIONS

The COVID-19 pandemic has negatively impacted family visitation and preterm infant developmental care practices in the NICU, both experiences associated with positive health benefits. Hospitals should create programs to improve family visitation and engagement, while also increasing staff-delivered developmental care. Careful attention should be paid to long-term follow up of preterm infants and families.

Improving Care in Neonatal Intensive Units During the COVID-19 Pandemic: A Survey on Electronic Health Communication

BACKGROUND

A novel virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) started spreading through Italy and the world from February 2020, and the pandemic threatened the family-centred care (FCC) model used in the neonatal intensive care unit (NICU). Teleconferences and video calls were employed to keep parents in contact with their babies. This study aimed to evaluate satisfaction and stress levels between parents in the telematic family-centred care group (T-FCC) versus the FCC group and the no Family-Centred Care (N-FCC) group. Methods A prospective cohort pilot study was carried out from April to May 2020. A parental stressor scale and the NICU satisfaction questionnaire were administered to parents at the time of discharge of their newborns. Parents in T-FCC group could see their newborns via video calls, while those in the FCC and N-FCC groups were extracted from our previously published database. Results Parents in the T-FCC group were more satisfied and less stressed than those in the N-FCC group. Experiences of the mothers and fathers in the T-FCC group were similar. However, the FCC group showed the best results. Conclusion The T-FCC group showed satisfaction with the quality of information received about their babies and felt that their privacy was considered and respected by the medical staff. Parents were also less stressed because they could monitor what happens to the baby through a video, however, they could not intervene if there was a problem. Data support the use of video calls to improve insight into clinical conditions and communication between doctors, nurses, and parents during the pandemic.

Automated Medical Care: Bradycardia Detection and Cardiac Monitoring of Preterm Infants

Background and Objectives: Prematurity of birth occurs before the 37th week of gestation and affects up to 10% of births worldwide. It is correlated with critical outcomes; therefore, constant monitoring in neonatal intensive care units or home environments is required. The aim of this work was to develop solutions for remote neonatal intensive supervision systems, which should assist medical diagnosis of premature infants and raise alarm at cardiac abnormalities, such as bradycardia. Additionally, the COVID-19 pandemic has put a worldwide stress upon the medical staff and the management of healthcare units. Materials and Methods: A traditional medical diagnosing scheme was set up, implemented with the aid of powerful mathematical operators. The algorithm was tailored to the infants' personal ECG characteristics and was tested on real ECG data from the publicly available PhysioNet database "Preterm Infant Cardio-Respiratory Signals Database". Different processing problems were solved: noise filtering, baseline drift removal, event detection and compression of medical data using the à trous wavelet transform. Results: In all 10 available clinical cases, the bradycardia events annotated by the physicians were correctly detected using the RR intervals. Compressing the ECG signals for remote transmission, we obtained compression ratios (CR) varying from 1.72 to 7.42, with the median CR value around 3. Conclusions: We noticed that a significant amount of noise can be added to a signal while monitoring using standard clinical sensors. We tried to offer solutions for these technical problems. Recent studies have shown that persons infected with the COVID-19 disease are frequently reported to develop cardiovascular symptoms and cardiac arrhythmias. An automatic surveillance system (both for neonates and adults) has a practical medical application. The proposed algorithm is personalized, no fixed reference value being applied, and the algorithm follows the neonate's cardiac rhythm changes. The performance depends on the characteristics of the input ECG. The signal-to-noise ratio of the processed ECG was improved, with a value of up to 10 dB.

Management of a pediatric burn center during the covid-19 pandemic

The aim of this study was to evaluate the results of an algorithm that was created to prevent coronavirus disease-2019 (COVID-19) transmission during the management of children with burns in a tertiary pediatric burn center. Children admitted to the burn center between May 2020 and November 2020 were prospectively evaluated for cause, burn depth, total body surface area (TBSA), length of stay, symptoms suggesting COVID-19, suspicious contact history, history of travel abroad, and COVID-19 polymerase chain reaction (PCR) test results. Patients were divided into two groups: unsuspected (Group 1) and suspected (Group 2), depending on any history of suspicious contact, travel abroad, and/or presence of symptoms. A total of 101 patients were enrolled in the study, which included 59 boys (58.4%) and 42 girls (41.6%). Group 1 included 79 (78.2%) patients, and Group 2 consisted of 22 (21.8%) patients. The most common cause of the burns was scald injuries (74.2%). The mean age, TBSA, and length of stay were 4.5 years, 12.0%, and 13.2 days, respectively. Four patients (3.9%) had a positive PCR test (two patients in each group). Comparing groups, males were more commonly found in Group 2 (p=0.042), but no differences were found for the other variables. No patients or burn center staff members developed COVID-19 during the course of hospitalization. In conclusion, every child should be tested for COVID-19 upon admission to a burn unit, and a modified algorithm should be constructed for the handling and management of pediatric burn patients.

Coronavirus Disease 2019 in Children

Since its appearance in Wuhan in mid-December 2019, acute respiratory syndrome coronavirus 2 (SARS-CoV-2) related 19 coronavirus disease (COVID-19) has spread dramatically worldwide. It soon became apparent that the incidence of pediatric COVID-19 was much lower than the adult form. Morbidity in children is characterized by a variable clinical presentation and course. Symptoms are similar to those of other acute respiratory viral infections, the upper airways being more affected than the lower airways. Thus far, over 90% of children who tested positive for the virus presented mild or moderate symptoms and signs. Most children were asymptomatic, and only a few cases were severe, unlike in the adult population. Deaths have been rare and occurred mainly in children with underlying morbidity. Factors as reduced angiotensin-converting enzyme receptor expression, increased activation of the interferon-related innate immune response, and trained immunity have been implicated in the relative resistance to COVID-19 in children, however the underlying pathogenesis and mechanism of action remain to be established. While at the pandemic outbreak, mild respiratory manifestations were the most frequently described symptoms in children, subsequent reports suggested that the clinical course of COVID-19 is more complex than initially thought. Thanks to the experience acquired in adults, the diagnosis of pediatric SARS-CoV-2 infection has improved with time. Data on the treatment of children are sparse, however, several antiviral trials are ongoing. The purpose of this narrative review is to summarize current understanding of pediatric SARS-CoV-2 infection and provide more accurate information for healthcare workers and improve the care of patients.

Improving the uptake of Kangaroo Mother Care in neonatal units: A narrative review and conceptual framework

Kangaroo Mother Care is a beneficial intervention for high-risk infants; however, global uptake is lacking. Recent systematic reviews have collated the numerous studies that identify diverse barriers and enablers to the use of Kangaroo Mother Care. In this narrative review, we combine the findings of these systematic reviews with more recent studies to propose a conceptual framework, encompassing factors that may affect the initiation and maintenance of Kangaroo Mother Care in neonatal units. CONCLUSION: This conceptual framework includes parental, healthcare professional, and healthcare system factors, and highlights the potential interplay between them. In line with this, we suggest strategies to improve the uptake of Kangaroo Mother Care in neonatal units.

Sensory Stimulation in the NICU Environment: Devices, Systems, and Procedures to Protect and Stimulate Premature Babies

Prematurity deprives infants of the prenatal sensory stimulation essential to their correct development; in addition, the stressful environment of the NICU impacts negatively on their growth. The purpose of this review was to investigate the effects of NICU noise pollution on preterm infants and parents. We focused on the systems and projects used to control and modulate sounds, as well as on those special devices and innovative systems used to deliver maternal sounds and vibrations to this population. The results showed beneficial effects on the preterm infants in different areas such as physiological, autonomic, and neurobehavioral development. Although most of these studies highlight positive reactions, there is also a general acknowledgement of the current limits: small and heterogeneous groups, lack of structured variable measurements, systematic control groups, longitudinal studies, and normative values. The mother's presence is always preferred, but the use of music therapy and the devices analyzed, although not able to replace her presence, aim to soften her absence through familiar and protective stimuli, which is a very powerful aid during the COVID-19 pandemic.

The Collateral Impact of COVID-19 Emergency on Neonatal Intensive Care Units and Family-Centered Care: Challenges and Opportunities

The ongoing Coronavirus disease 2019 (COVID-19) pandemic is disrupting most specialized healthcare services worldwide, including those for high-risk newborns and their families. Due to the risk of contagion, critically ill infants, relatives and professionals attending neonatal intensive care units (NICUs) are undergoing a profound remodeling of the organization and quality of care. In particular, mitigation strategies adopted to combat the COVID-19 pandemic may hinder the implementation of family-centered care within the NICU. This may put newborns at risk for several adverse effects, e.g., less weight gain, more nosocomial infections, increased length of NICU stay as well as long-term worse cognitive, emotional, and social development. This article aims to contribute to deepening the knowledge on the psychological impact of COVID-19 on parents and NICU staff members based on empirical data from the literature. We also provided evidence-based indications on how to safely empower families and support NICU staff facing such a threatening emergency, while preserving the crucial role of family-centered developmental care practices.

The aftermath of SARS-CoV-2 in NICU: saving or checking accounts? Projected cost-effectiveness analysis

In the aftermath of the SARS-CoV-2 pandemic, we revised the cost-effectiveness of the exploited interventions in neonatal intensive care unit, to redefine future strategies for hospital management. Costs were revised with respect to the lockdown R0 or under different R0 scenarios to estimate the cost-effectiveness of the screening program adopted. Weekly nasopharyngeal swabs for parents, neonates, and personnel were the major cost during the pandemic, although they effectively reduced the number of cases in our unit.Conclusion: Parents and healthcare personnel testing appears to be an effective strategy due to the high number of contact they have within the hospital environment and outside, able to minimize the cases within our unit. What is Known: • Costs of universal COVID-19 tests for parents, neonates, and NICU personnel have not been evaluated during the COVID-19 pandemic in neonatal intensive care unit in Europe. What is New: • Weekly nasopharyngeal swabs for parents, neonates, and personnel were the major cost during the COVID-19 pandemic in NICU. • Parents and healthcare personnel testing was effective to reduce costs related to COVID-19 due to the high number of contact they have within the hospital environment and outside.

Care of hospitalized infants and their families during the COVID-19 pandemic: an international survey

This research study explored changes in family-centered care practices for hospitalized infants and families due to the COVID-19 pandemic. This exploratory descriptive study used a 49-item online survey, distributed to health care professionals working with hospitalized infants and families. The sample consisted of 96 participants from 22 countries. Prior to the COVID-19 pandemic, 87% of units welcomed families and 92% encouraged skin-to-skin care. During the pandemic, family presence was restricted in 83% of units, while participation in infant care was restricted in 32%. Medium-sized (20-40 beds) units applied less restriction than small (<20 beds) units (p = 0.03). Units with single-family rooms that did not restrict parental presence, implemented fewer restrictions regarding parents' active participation in care (p = 0.02). Restrictions to families were not affected by geographic infection rates or developmental care education of health care professionals. Restrictions during the pandemic increased separation between the infant and family.

Universal screening of high-risk neonates, parents, and staff at a neonatal intensive care unit during the SARS-CoV-2 pandemic

Since February 21, 2020, SARS-CoV-2 has spread exponentially worldwide. Neonatal patients needing intensive care are considered a vulnerable population. To report the results of a policy based on multi-timepoint surveillance for SARS-CoV-2 of all neonates admitted to the neonatal intensive care unit (NICU), their parents, and all healthcare providers in a part of Italy with a high prevalence of the infection. Observational study conducted from 21 February to 21 April 2020. Intervention consisted of (a) parental triage on arrival at the neonatal ward; (b) universal testing with nasopharyngeal swabs and blood testing for SARS-CoV-2 IgM and IgG antibodies; (c) use of continuous personal protective equipment at the NICU by parents and staff. A total of 6726 triage procedures were performed on 114 parents, and 954 nasopharyngeal swabs were collected from 226 individuals. Five (2.2%) asymptomatic individuals (2 parents and 3 healthcare providers) tested positive on nasopharyngeal swabs and were kept isolated for 14 days. Of 75 admitted newborn, no one tested positive on nasopharyngeal swabs or antibody tests. Three parents presented with fever or flu-like symptoms at triage; they tested negative on swabs.Conclusion: With universal screening of neonates, parents, and staff, there were no cases of SARS-CoV-2 infection among the neonates admitted to a NICU in an area with a high incidence of SARS-CoV-2. Our experience could be usefully compared with other strategies with a view to developing future evidence-based guidelines for managing high-risk neonates in case of new epidemics. What is Known: • The novel coronavirus named SARS-CoV-2 has since spread worldwide at a remarkable rate, with more than 2.5 million confirmed cases. • Pediatric population may be less affected from COVID-19 than adult population but infants and newborn babies seem to be more vulnerable to SARS-CoV-2 infection. What is New: • Using an approach based on triage; testing with nasopharyngeal swabs and serology; and use of personal protective equipment, there were no cases of SARS-CoV-2 infection among neonates in a NICU in a high incidence of SARS-CoV-2 area. • Positive and asymptomatic individuals were identified and isolated early allowing the containment of infection's spread among healthcare providers and parents.

Impact of the COVID-19 pandemic on developmental care practices for infants born preterm

OBJECTIVES

To assess the impact of the COVID-19 pandemic on rates of hospital visitation and rates and durations of developmental care practices for infants born preterm delivered by both families and clinical staff.

METHODS

We analyzed electronic medical record data from infants born at less than 32 weeks gestational age (GA) cared for in the Lucile Packard Children's Hospital neonatal intensive care unit (NICU) in a COVID-19-affected period (March 8, 2020 to May 31, 2020) and the analogous period in 2019. Our final sample consisted of 52 infants ( n =27, 2019 cohort; n =25, 2020 cohort). Rates of family visitation and of family- and clinical staff-delivered developmental care were compared across cohorts, adjusting for GA at start of study period.

RESULTS

Results indicated that families of infants in the 2020 cohort visited less frequently (47% of available days) than those in the 2019 cohort (97%; p =0.001). Infants received developmental care activities less frequently in the 2020 cohort (3.51 vs. 4.72 activities per day; p =0.04), with a lower number of minutes per day (99.91 vs. 145.14; p =0.04) and a shorter duration per instance (23.41 vs. 29.65; p =0.03). Similar reductions occurred in both family- and staff-delivered developmental care activities.

CONCLUSIONS

The COVID-19 pandemic has negatively impacted family visitation and preterm infant developmental care practices in the NICU, both experiences associated with positive health benefits. Hospitals should create programs to improve family visitation and engagement, while also increasing staff-delivered developmental care. Careful attention should be paid to long-term follow up of preterm infants and families.