Perinatal-Neonatal Management of COVID-19 Infection - Guidelines of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), National Neonatology Forum of India (NNF), and Indian Academy of Pediatrics (IAP)

COVID-19 and mortality among infants: Evidence from India

We present the first survey-based evidence on infant mortality in a developing country during the COVID-19 pandemic. Employing high-quality, nationally representative data from India, our analyses document a significant rise in mortality rates among infants during a six month period in 2020 covering the pandemic and the ensuing lockdown. The difference-in-differences estimates show that mortality among infants at ages 1, 3, and 6 months increased by about 9, 13, and 16 deaths per 1000 births, corresponding to an increase of 30, 42, and 44 percent, respectively. Since COVID-19 had minimal direct impact on infant mortality, our estimates likely capture some of the indirect effects on infant mortality through income shocks, reduced healthcare access, and behavioral changes such as avoidance of hospitals for maternal care during this period.

Potential Neurologic Manifestations of COVID-19 Infection in Neonates

In contrast to adults, neonates and infants with coronavirus disease 2019 (COVID-19) infection have milder symptoms and are less likely to require hospitalization. However, some neonates with COVID-19 can present with significant symptoms. Recent evidence suggests that neurologic manifestations of neonatal COVID-19 infection may be higher than initially thought. In this comprehensive review of the current literature, we summarize the clinical, laboratory, and radiologic findings, as well as potential management strategies for COVID-19-related neurologic illness in neonates. Although the growing brain may be affected by neurologic disease associated with COVID-19 infection, the few published studies on the long-term outcomes after COVID-19 infection in neonates and infants provide conflicting results. Larger collaborative clinical studies are needed to determine whether COVID-19 infection in neonates has long-term neurodevelopmental outcomes.

Communication to promote and support physical distancing for COVID-19 prevention and control

BACKGROUND

This review is an update of a rapid review undertaken in 2020 to identify relevant, feasible and effective communication approaches to promote acceptance, uptake and adherence to physical distancing measures for COVID-19 prevention and control. The rapid review was published when little was known about transmission, treatment or future vaccination, and when physical distancing measures (isolation, quarantine, contact tracing, crowd avoidance, work and school measures) were the cornerstone of public health responses globally. This updated review includes more recent evidence to extend what we know about effective pandemic public health communication. This includes considerations of changes needed over time to maintain responsiveness to pandemic transmission waves, the (in)equities and variable needs of groups within communities due to the pandemic, and highlights again the critical role of effective communication as integral to the public health response.

OBJECTIVES

To update the evidence on the question 'What are relevant, feasible and effective communication approaches to promote acceptance, uptake and adherence to physical distancing measures for COVID-19 prevention and control?', our primary focus was communication approaches to promote and support acceptance, uptake and adherence to physical distancing.

SECONDARY OBJECTIVE

to explore and identify key elements of effective communication for physical distancing measures for different (diverse) populations and groups.

SEARCH METHODS

We searched MEDLINE, Embase and Cochrane Library databases from inception, with searches for this update including the period 1 January 2020 to 18 August 2021. Systematic review and study repositories and grey literature sources were searched in August 2021 and guidelines identified for the eCOVID19 Recommendations Map were screened (November 2021).

SELECTION CRITERIA

Guidelines or reviews focusing on communication (information, education, reminders, facilitating decision-making, skills acquisition, supporting behaviour change, support, involvement in decision-making) related to physical distancing measures for prevention and/or control of COVID-19 or selected other diseases (sudden acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), influenza, Ebola virus disease (EVD) or tuberculosis (TB)) were included. New evidence was added to guidelines, reviews and primary studies included in the 2020 review.

DATA COLLECTION AND ANALYSIS

Methods were based on the original rapid review, using methods developed by McMaster University and informed by Cochrane rapid review guidance. Screening, data extraction, quality assessment and synthesis were conducted by one author and checked by a second author. Synthesis of results was conducted using modified framework analysis, with themes from the original review used as an initial framework.

MAIN RESULTS

This review update includes 68 studies, with 17 guidelines and 20 reviews added to the original 31 studies. Synthesis identified six major themes, which can be used to inform policy and decision-making related to planning and implementing communication about a public health emergency and measures to protect the community. Theme 1: Strengthening public trust and countering misinformation: essential foundations for effective public health communication Recognising the key role of public trust is essential. Working to build and maintain trust over time underpins the success of public health communications and, therefore, the effectiveness of public health prevention measures. Theme 2: Two-way communication: involving communities to improve the dissemination, accessibility and acceptability of information Two-way communication (engagement) with the public is needed over the course of a public health emergency: at first, recognition of a health threat (despite uncertainties), and regularly as public health measures are introduced or adjusted. Engagement needs to be embedded at all stages of the response and inform tailoring of communications and implementation of public health measures over time. Theme 3: Development of and preparation for public communication: target audience, equity and tailoring Communication and information must be tailored to reach all groups within populations, and explicitly consider existing inequities and the needs of disadvantaged groups, including those who are underserved, vulnerable, from diverse cultural or language groups, or who have lower educational attainment. Awareness that implementing public health measures may magnify existing or emerging inequities is also needed in response planning, enactment and adjustment over time. Theme 4: Public communication features: content, timing and duration, delivery Public communication needs to be based on clear, consistent, actionable and timely (up-to-date) information about preventive measures, including the benefits (whether for individual, social groupings or wider society), harms (likewise) and rationale for use, and include information about supports available to help follow recommended measures. Communication needs to occur through multiple channels and/or formats to build public trust and reach more of the community. Theme 5: Supporting behaviour change at individual and population levels Supporting implementation of public health measures with practical supports and services (e.g. essential supplies, financial support) is critical. Information about available supports must be widely disseminated and well understood. Supports and communication related to them require flexibility and tailoring to explicitly consider community needs, including those of vulnerable groups. Proactively monitoring and countering stigma related to preventive measures (e.g. quarantine) is also necessary to support adherence. Theme 6: Fostering and sustaining receptiveness and responsiveness to public health communication Efforts to foster and sustain public receptiveness and responsiveness to public health communication are needed throughout a public health emergency. Trust, acceptance and behaviours change over time, and communication needs to be adaptive and responsive to these changing needs. Ongoing community engagement efforts should inform communication and public health response measures.

AUTHORS' CONCLUSIONS

Implications for practice Evidence highlights the critical role of communication throughout a public health emergency. Like any intervention, communication can be done well or poorly, but the consequences of poor communication during a pandemic may mean the difference between life and death. The approaches to effective communication identified in this review can be used by policymakers and decision-makers, working closely with communication teams, to plan, implement and adjust public communications over the course of a public health emergency like the COVID-19 pandemic. Implications for research Despite massive growth in research during the COVID-19 period, gaps in the evidence persist and require high-quality, meaningful research. This includes investigating the experiences of people at heightened COVID-19 risk, and identifying barriers to implementing public communication and protective health measures particular to lower- and middle-income countries, and how to overcome these.

The Effect of Virtual Education in Parenting Skills on the Parenting Sense of Competence in First-time Mothers with a 0-2-year-old Baby: A Quasi-experimental Study

Background

Parental competence is a key aspect of parenting. Since they have no previous experience of having a baby, first-time mothers should acquire certain skills to be competent enough in caring for their baby. The present study aimed to investigate the effect of virtual education in parenting skills on the parenting competence of first-time mothers with a 0-2-year-old baby.

Methods

This quasi-experimental study was conducted through convenience sampling; 72 first-time mothers were selected from 12 healthcare centers, 62 of whom met the criteria for entering the study, and divided into an experimental (n=31) and a control (n=31) group. The mothers in the experimental group received virtual education in parenting skills in six sessions, each lasting 10 minutes for two weeks. The data were collected using a demographics questionnaire and Gibaud-Wallston's parenting sense of competence scale. Sense of competence was assessed in three stages: before, immediately after, and one month after the completion of the intervention. The collected data were analyzed using SPSS v. 22 at a significance level of less than 0.05.

Results

Results showed a statistically significant increase in the experimental group's parenting competence mean score immediately and one month after the intervention (P<0.001). There was a statistically significant difference between the mean scores of the study groups as measured immediately after (P=0.043) and one month after the intervention (P<0.001).

Conclusion

Virtual education of parenting skills could have a positive impact on the mothers' parenting competence. It is suggested that first-time mothers should be educated in parenting skills on a face-to-face basis in maternity wards and online after discharge.

Implementing recommended breastfeeding practices in healthcare facilities in India during the COVID-19 pandemic: a scoping review of health system bottlenecks and potential solutions

Background

Breastfeeding practices in institutional settings got disrupted during the COVID-19 pandemic. We reviewed the challenges faced and the "work-around" solutions identified for implementing recommended breastfeeding practices in institutionalized mother-newborn dyads in resource constrained settings during the pandemic with the aim to identify learnings that could be potentially adapted to the Indian and relatable contexts, for building resilient health systems.

Methods

We conducted a scoping review of literature using the PRISMA ScR Extension guidelines. We searched the Medline via PubMed and Web of Science databases for literature published between 1st December 2019 and 15th April 2022. We included original research, reviews, and policy recommendations published in English language and on India while others were excluded. Further, we searched for relevant gray literature on Google (free word search), websites of government and major professional bodies in India. Three reviewers independently conducted screening and data extraction and the results were displayed in tabular form. Challenges and potential solutions for breastfeeding were identified and were categorized under one or more suitable headings based on the WHO building blocks for health systems.

Results

We extracted data from 28 papers that were deemed eligible. Challenges were identified across all the six building blocks. Lack of standard guidelines for crisis management, separation of the newborn from the mother immediately after birth, inadequate logistics and resources for infection prevention and control, limited health workforce, extensive use of formula and alternative foods, inconsistent quality of care and breastfeeding support, poor awareness among beneficiaries about breastfeeding practices (and especially, about its safety during the pandemic) were some of the challenges identified. The solutions primarily focused on the development of standard guidelines and operating procedures, restricted use of formula, use of telemedicine services for counseling and awareness and improving resource availability for risk mitigation through strategic mobilization.

Conclusion

The COVID-19 pandemic has provided rich learning opportunities for health system strengthening in India. Countries must strengthen learning mechanisms to identify and adapt best practices from within their health systems and from other relatable settings.

Evolution of National Guidelines on Medicines Used to Treat COVID-19 in Pregnancy in 2020-2022: A Scoping Review

The lack of inclusion of pregnant women in clinical trials evaluating the effectiveness of medicines to treat COVID-19 has made it difficult to establish evidence-based treatment guidelines for pregnant women. Our aim was to provide a review of the evolution and updates of the national guidelines on medicines used in pregnant women with COVID-19 published by the obstetrician and gynecologists' societies in thirteen countries in 2020-2022. Based on the results of the RECOVERY (Randomized Evaluation of COVID-19 Therapy) trial, the national societies successively recommended against prescribing hydroxychloroquine, lopinavir-ritonavir and azithromycin. Guidelines for remdesivir differed completely between countries, from compassionate or conditional use to recommendation against. Nirmatrelvir-ritonavir was authorized in Australia and the UK only in research settings and was no longer recommended in the UK at the end of 2022. After initial reluctance to use corticosteroids, the results of the RECOVERY trial have enabled the recommendation of dexamethasone in case of severe COVID-19 since mid-2020. Some societies recommended prescribing tocilizumab to pregnant patients with hypoxia and systemic inflammation from June 2021. Anti-SARS-CoV-2 monoclonal antibodies were authorized at the end of 2021 with conditional use in some countries, and then no longer recommended in Belgium and the USA at the end of 2022. The gradual convergence of the recommendations, although delayed compared to the general population, highlights the importance of the inclusion of pregnant women in clinical trials and of international collaboration to improve the pharmacological treatment of pregnant women with COVID-19.

COVID-19 Disease in Under-5 Children: Current Status and Strategies for Prevention including Vaccination

Since the coronavirus disease (COVID-19) pandemic hit the globe in early 2020, we have steadily gained insight into its pathogenesis; thereby improving surveillance and preventive measures. In contrast to other respiratory viruses, neonates and young children infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) have a milder clinical presentation, with only a small proportion needing hospitalization and intensive care support. With the emergence of novel variants and improved testing services, there has been a higher incidence of COVID-19 disease reported among children and neonates. Despite this, the proportion of young children with severe disease has not increased. Key mechanisms that protect young children from severe COVID-19 disease include the placental barrier, differential expression of angiotensin-converting enzyme 2 (ACE-2) receptors, immature immune response, and passive transfer of antibodies via placenta and human milk. Implementing mass vaccination programs has been a major milestone in reducing the global disease burden. However, considering the lower risk of severe COVID-19 illness in young children and the limited evidence about long-term vaccine safety, the risk-benefit balance in children under five years of age is more complex. In this review, we do not support or undermine vaccination of young children but outline current evidence and guidelines, and highlight controversies, knowledge gaps, and ethical issues related to COVID-19 vaccination in young children. Regulatory bodies should consider the individual and community benefits of vaccinating younger children in their local epidemiological setting while planning regional immunization policies.

Adopting international recommendations to design a model for maternal health service to cope with pandemic disruption for Indonesian primary care

BACKGROUND

Limited evidence is available as the reference for the model of care on providing maternity care in low-and-middle-income countries (LMICs) to cope with pandemic disruption. This study aimed to adopt international recommendations to develop the model of care with the context of Indonesian settings.

METHODS

Four codesign workshops and substitute interviews with stakeholders, covering the (i) exploration of service provision during the pandemic, (ii) adoption of international recommendations, (iii) designing and (iv) finalising model of care for maternal health services in primary care under the COVID-19 pandemic. The study took place in Yogyakarta Province Indonesia from July-November 2021. The participants were general practitioners, midwives, nurses, patients, and obstetricians. The data were analysed thematically.

RESULTS

Twenty-three participants were recruited. As many as 23, 16, 14 and 16 participants participated in the first to fourth codesign workshops or substitute interviews. Key recommendations agreed upon in the workshop were health screening, maintaining antenatal-postnatal breastfeeding care, limiting visitors, using telemedicine, and creating a multidisciplinary team to provide the care. A model of care for improving maternal service was also agreed and received suggestions from the participants. Identified barriers to the recommendation implementation, such as the available clinical resources and negotiating providers' authority in practice.

CONCLUSION

Recommendations and the model of care for improving maternity care in Indonesia are beneficial to be implemented in Indonesian primary care during the COVID-19 pandemic. Further research includes pilot studies to explore the acceptability of the model and recommendation implementation in practice.

Recommendations for improving maternal health services in Indonesian primary care under the COVID-19 pandemic: Results of a systematic review and appraisal of international guidelines

BACKGROUND

A large volume of evidence and reviews about COVID-19 recommendations have been published; however, only a few provide recommendations on maternal health services ready for their adoption in Indonesia. This review aims to identify a set of potential recommendations for improving maternal care in the Indonesian primary care setting under the COVID-19 pandemic.

METHODS

A literature search to identify articles that cover a set of recommendations, or maternal guideline under the SARS-COV-1 outbreak or COVID-19 pandemic that were published from 2020 to 1 November 2022 was applied in six academic databases. The search used various keywords and phrases of 'maternal', 'model' and 'coronavirus', and excluded reviews and those evaluating interventions or medicine prescription. The eligible guidelines were appraised using AGREE II instrument, coded, and thematically analysed for their potential adoption to Indonesian settings.

FINDINGS

Fourteen guidelines were fully reviewed, and most of them had high AGREE II scores. Two main themes emerged from the analysis: clinical and supporting arrangements for maternal health services. Potential challenges for the implementation of these recommendations in Indonesia were also discussed.

CONCLUSION AND IMPLICATION FOR PRACTICE

Potential recommendations for improving maternal health for women in Indonesia under the COVID-19 pandemic both on the clinical and supporting services arrangements have been identified. Available clinical resources, different context of providers' practice authority and patients' literacy may challenge their implementation in practice. Further research is needed to seek consensus on the recommendation adoption in practice and to desirably redesign maternal health service in Indonesia.

Impact of Maternal-Newborn Separation in Italian Women with Suspected COVID-19 Infection on Psychopathological Symptoms and Quality of Interactions during Breastfeeding

INTRODUCTION

Before the COVID-19 pandemic, proximity between mothers and their newborn infants was at the core of sanitary guidelines. With the aim of stopping the virus transmission from mothers to infants and possible physical dangers due to the infection, some hospitals discouraged or even prohibited skin-to-skin contact and breastfeeding.

METHOD

This study recruited 180 dyads in private and public hospitals in Italy with the aim of verifying whether mother-infant separation after delivery is associated with higher maternal psychopathological distress (assessed through the SCL-90-R) and poorer quality of dyadic interactions during breastfeeding (evaluated through the SVIA).

RESULTS

Our results showed that mothers separated from their infants displayed more anxiety, depression, and obsessive-compulsive symptoms and a lower quality of feeding interactions on all the subscales of the SVIA (mother's affective state; interactive conflict; food refusal behavior; dyad's affective state).

CONCLUSION

In light of these results, our study suggests that separating mothers from their newborns is associated with increased psychopathological symptoms in mothers and poorer feeding interactions. These issues have been posited as key predictors of maladaptive outcomes in infants' later lives; therefore, health services must fully consider the short- and long-term consequences of separating mothers and infants in their policies in the event of future pandemics.

Barriers and enablers of breastfeeding in mother-newborn dyads in institutional settings during the COVID-19 pandemic: A qualitative study across seven government hospitals of Delhi, India

Introduction

The COVID-19 pandemic disrupted newborn care and breastfeeding practices across most healthcare facilities. We undertook this study to explore the barriers and enablers for newborn care and breastfeeding practices in hospitals in Delhi, India for recently delivered mother (RDM)-newborn dyads during the first wave of the COVID-19 pandemic (2020) and inductively design a "pathway of impaction" for informing mitigatory initiatives during the current and future pandemics, at least in the initial months.

Materials and methods

We used an exploratory descriptive design (qualitative research method) and collected information from seven leading public health facilities in Delhi, India. We conducted separate interviews with the head and senior faculty from the Departments of Pediatrics/Neonatology (n = 12) and Obstetrics (n = 7), resident doctors (n = 14), nurses (labor room/maternity ward; n = 13), and RDMs (n = 45) across three profiles: (a) COVID-19-negative RDM with healthy newborn (n = 18), (b) COVID-19-positive RDM with healthy newborn (n = 19), and (c) COVID-19 positive RDM with sick newborn needing intensive care (n = 8) along with their care-giving family members (n = 39). We analyzed the data using grounded theory as the method and phenomenology as the philosophy of our research.

Results

Anxiety among clients and providers, evolving evidence and advisories, separation of the COVID-positive RDM from her newborn at birth, providers' tendency to minimize contact duration and frequency with COVID-positive mothers, compromised counseling on breastfeeding, logistic difficulties in expression and transportation of COVID-positive mother's milk to her baby in the nursery, COVID restrictions, staff shortage and unavailable family support in wards and nursery, and inadequate infrastructure were identified as major barriers. Keeping the RDM-newborn together, harmonization of standard operating procedures between professional associations and within and between departments, strategic mobilization of resources, optimization of human resources, strengthening client-provider interaction, risk triaging, leveraging technology, and leadership-in-crisis-situations were notable enablers.

Conclusion

The separation of the RDM and newborn led to a cascade of disruptions to newborn care and breastfeeding practices in the study institutions. Separating the newborn from the mother should be avoided during public health emergencies unless there is robust evidence favoring the same; routine institutional practices should be family centered.

A short-term follow-up study on breastfeeding practices, growth parameters and immunization practices among babies born to COVID-19 positive mothers in a tertiary care hospital

We aimed to study the impact of the COVID-19 pandemic on exclusive breastfeeding (EBF) rate and routine follow-up practices including immunization. A total of 62 neonates born to COVID-19 positive mothers and an equal number of neonates born to COVID-19 negative mothers were prospectively evaluated for EBF rate and routine neonatal follow-up practices including delay (>7 days) in routine immunization at 3 months follow-up. We further tried to compare the results across two epochs (epoch 1, March-June 2020 and epoch 2, July-November 2020). There was significantly lesser number of babies born to COVID-19 positive mothers on EBF at 3 months of age when compared with the control group (45.1% vs. 96.7%, p = 0.00) as well it was significantly lesser in epoch 1 when compared with epoch 2 (16% vs. 74%, p = 0.00). Further, a significantly higher number of babies born to COVID-19 positive mothers had their routine immunization delayed with no significant difference across the epochs. There was no significant difference in growth parameters between babies born to COVID-19 positive mother when compared with the control group as well as across the epochs. The COVID-19 pandemic has significantly disrupted the EBF rates as well as hampered the routine immunization practices among babies born to COVID-19 positive mothers. Although such practices got improved after the implementation of evidence-based national guidelines, but it is still much below when compared with those born to COVID-19 negative mother.

Systematic review and critical evaluation of quality of clinical practice guidelines on the management of SARS-CoV-2 infection in pregnancy

OBJECTIVE

To systematically identify and critically assess the quality of clinical practice guidelines for the management of SARS-CoV-2 infection in pregnancy.

DATA SOURCES

Medline, Scopus, and ISI Web of Science databases were searched until February 15, 2022.

STUDY ELIGIBILITY CRITERIA

Inclusion criteria were clinical practice guidelines on the management of SARS-CoV-2 infection in pregnancy. The risk of bias and quality assessments of the included clinical practice guidelines were performed using the Appraisal of Guidelines for REsearch and Evaluation II tool, which is considered the gold standard for quality assessment of clinical practice guidelines. To define a clinical practice guideline as of good quality, we adopted the cutoff score proposed by Amer et al: if the overall clinical practice guideline score was >60%, it was recommended.

METHODS

The following clinical points related to the management of pregnant women with SARS-CoV-2 infection were addressed: criteria for maternal hospitalization, recommendations for follow-up fetal growth scan, specific recommendations against invasive procedures, management of labor, timing of delivery, postpartum care, and vaccination strategy.

RESULTS

A total of 28 clinical practice guidelines were included. All recommended hospitalization only for severe disease; 46.1% (6/13) suggested a fetal growth scan after SARS-CoV-2 infection, whereas 23.1% (3/13) did not support this practice. Thromboprophylaxis with low-molecular-weight heparin was recommended in symptomatic women by 77.1% (7/9) of the clinical practice guidelines. None of the guidelines recommended administering corticosteroids only for the presence of SARS-CoV-2 infection in preterm gestation, unless specific obstetrical indication exists. Elective induction of labor from 39 weeks of gestation was suggested by 18.1% (2/11) of the clinical practice guidelines included in the present review, whereas 45.4% (5/11) did not recommend elective induction unless other obstetrical indications coexisted. There were 27% (3/11) of clinical practice guidelines that suggested shortening of the second stage of labor, and active pushing was supported by 18.1% (2/11). There was general agreement among the clinical practice guidelines in not recommending cesarean delivery only for the presence of maternal infection and in recommending vaccine boosters at least 6 months after the primary series of vaccination. The Appraisal of Guidelines for REsearch and Evaluation II standardized domain scores for the first overall assessment of clinical practice guidelines had a mean of 50% (standard deviation±21.82%), and 9 clinical practice guidelines scored >60%.

CONCLUSION

A significant heterogeneity was found in some of the main aspects of the management of SARS-CoV-2 infection in pregnancy, as reported by the published clinical practice guidelines.

COVID-19 pandemic effects on the distribution of healthcare services in India: A systematic review

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has brought fundamental changes to our problems and priorities, especially those related to the healthcare sector. India was one of the countries severely affected by the harsh consequences of the COVID-19 pandemic.

AIM

To understand the challenges faced by the healthcare system during a pandemic.

METHODS

The literature search for this review was conducted using PubMed, EMBASE, Scopus, Web of Science, and Google Scholar. We also used Reference Citation Analysis (RCA) to search and improve the results. We focused on the published scientific articles concerned with two major vital areas: (1) The Indian healthcare system; and (2) COVID-19 pandemic effects on the Indian healthcare system.

RESULTS

The Indian healthcare system was suffering even before the pandemic. The pandemic has further stretched the healthcare services in India. The main obstacle in the healthcare system was to combat the rising number of communicable as well as noncommunicable diseases. Besides the pandemic measures, there was a diversion of focus of the already established healthcare services away from the chronic conditions and vaccinations. The disruption of the vaccination services may have more severe short and long-term consequences than the pandemic’s adverse effects.

CONCLUSION

Severely restricted resources limited the interaction of the Indian healthcare system with the COVID-19 pandemic. Re-establishment of primary healthcare services, maternal and child health services, noncommunicable diseases programs, National Tuberculosis Elimination Program, etc. are important to prevent serious long-term consequences of this pandemic.

Systematic Identification and Critical Appraisal of Pediatric COVID-19 Guidelines Applicable in India

OBJECTIVE

To systematically identify and critically appraise the methodological quality of pediatric guidelines applicable to management of COVID-19 in India.

METHODS

Pediatric COVID-19 guidelines applicable to India, published until 30 April 2021, were identified through a systematic search across ten databases. Each was critically appraised for methodological quality using the AGREE-II tool, by at least two appraisers. Median (interquartile range) of the total score and domain-wise scores were calculated, and compared for Indian vs. foreign guidelines, updated vs. original versions of guidelines, and those developed earlier vs. later in the pandemic.

RESULTS

A total of 62 guidelines was identified. Only 8 (12.9%) were published in India. The overall AGREE-II score ranged from 4.7% to 72.8%; with median (IQR) 37.9% (29.4, 48.6). This suggested overall low(er) methodological quality. The median (IQR) domain-wise scores were as follows: Scope and Purpose 66.7% (58.3, 83.3), Stakeholder Involvement 41.7% (30.6, 83.3), Rigor of Development 23.4% (14.8, 37.5), Clarity of Presentation 59.7% (50.0, 75.0), Applicability 27.1% (18.8, 33.3), and Editorial Independence 8.3% (0.0, 45.8). This suggested diversity in quality of different aspects of the guidelines, with very low quality in the critical domain of methodological rigor. There were no statistically significant differences in the overall scores of Indian vs. foreign guidelines, updated versions vs. original versions, and those developed earlier vs. later in the pandemic.

CONCLUSION

The currently available pediatric COVID-19 guidelines have low methodological quality, adversely affecting their credibility, validity, and applicability. Urgent corrective strategies are presented for consideration.

Protecting Breastfeeding during the COVID-19 Pandemic: A Scoping Review of Perinatal Care Recommendations in the Context of Maternal and Child Well-Being

The objective of this scoping review is to determine to what extent the recommendations on perinatal care protect breastfeeding during the COVID-19 pandemic. The review follows the PRISMA ScR Extension guidelines. The research was conducted in Scopus, Medline via Pubmed, and Web of Science databases from 1 March 2020 to 31 May 2021, using 392 combinations of keywords. We searched for reviews and original papers published in English providing recommendations on delivery mode, companion during labor, the possibility of skin-to-skin contact (SSC), breastfeeding, and visitors policy. After screening, 86 out of 8416 publications qualified for data extraction. The majority of them indicated that COVID-19 infection is not a sufficient reason for a cesarean section; however, on a national level, cesarean births in severely ill patients were overrepresented. A significant number of recommendations deprived mothers of the necessary support during their labor and stay in the maternity ward. A shared decision-making model was hardly visible. Only the earliest COVID-19 recommendations suspended direct breastfeeding; in later publications, decisions were related to the mother's health, but other options of natural feeding were rarely discussed.

Clinical Outcome of Neonates Born to SARS-CoV-2 Positive Mothers in India: A Systematic Review and Meta-Analysis

During the SARS-CoV-2 pandemic, India accounted for 10-50% of cases reported across the world. Perinatal care from a developing country during this period has its own importance. This study was conducted to evaluate the health outcome of neonates born to SARS-CoV-2 positive mothers in India from the published literature by a systematic review and meta-analysis. Articles reporting neonates born from SARS-CoV-2 confirmed mothers in India, published in PubMed, Scopus®, and Embase® databases, were analyzed. After registration with the International Prospective Register of Systematic Reviews (PROSPERO), the study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes were the mode of delivery, perinatal asphyxia, preterm birth, breastfeeding, neonatal mortality, SARS-CoV-2 infectivity among neonates of SARS-CoV-2 mothers. The pooled rate was expressed with a 95% confidence interval. Heterogeneity and study level effect size were assessed using I² statistics and DerSimonian and Laird random effect method of meta-analysis. Data analysis was made by Stata 15.1 (StataCorp LLC, College Station, Texas, USA). Total 3,551 neonates born from 3,542 SARS-CoV-2 positive mothers were included from 14 studies (four prospective and 10 retrospective studies). The pooled rates of premature birth, Caesarean delivery, breastfeeding, and neonatal mortality were 18.89%, 55.89%, 67.79%, respectively, with 12.64/1000 live births. SARS-CoV-2 positivity rate was 5.28%; 11.76% were symptomatic, and five (1.7%) died from 281 SARS-CoV-2 positive neonates. There was an increase in the number of Caesarean delivery, premature birth, and lower mortality among neonates born to SARS-CoV-2 positive mothers compared to the Indian neonatal database. Around five percent of neonates delivered to SARS-CoV-2 positive mothers were infected, and the majority of them had good clinical outcomes.

Nursing care recommendation for pediatric COVID-19 patients in the hospital setting: A brief scoping review

BACKGROUND

The hospitalization of children during the COVID-19 pandemic has affected their physical and mental health. Pediatric nurses have faced challenges in providing high-quality nursing care for children and their families. However, the pediatric nursing care recommendations for COVID-19 patients in the hospital setting remain unclear. The current scoping review provides recommendations for nursing interventions for pediatric COVID-19 patients in the hospital setting.

METHODS AND FINDINGS

The selected articles containing management and nursing recommendations for COVID-19 that have occurred in pediatric patients ages 0-19 years old. A search strategy was developed and implemented in seven databases. We included peer-reviewed articles that reported observational or interventional studies, as well as policy papers, guides or guidelines, letters and editorials, and web articles. A total of 134 articles and other documents relevant to this review were included. We categorized the results based on The Nursing Intervention Classification (NIC) taxonomy which consists of six domains (e.g., Physiological: Basic); eleven classes (e.g., Nutrition Support); and eighteen intervention themes (e.g., Positioning, Family Presence Facilitation, Family Support, and Discharge Planning).

CONCLUSION

Apart from the intervention of physical problems, there is a need to promote patient- and family-centered care, play therapy, and discharge planning to help children and families cope with their new situation.

Self-Screening as an Effort to Prevent the Risk of Exposure to COVID-19 in Pregnant Women

BACKGROUND: Pregnant women in the era of the COVID-19 pandemic were listed as one of the vulnerable groups at risk of being infected with COVID-19 because during pregnancy there were changes in gestational physiology and immunological changes in the body’s system. Changes in the immune system that occur during pregnancy can make pregnant women more susceptible to coronavirus infection and more at risk of experiencing severe and fatal disease symptoms. AIM: The purpose of this study was to analyze the effect of self-screening on behavior to prevent the risk of being exposed to COVID-19 in pregnant women. METHODS: This type of research is experimental using a randomized controlled trial research design. This research was conducted for 2 weeks in August–September 2021. The population of this study was pregnant women in Surabaya. The sampling technique used consecutive sampling technique and was divided into two groups, namely, the intervention group with 39 respondents and the control group with 39 respondents. Data analysis used the Wilcoxon signed ranks test with a significance value of p < 0.05. The questionnaire used in this study was designed using a reference and behavioral theory approach with a reliability of 0.89 and a validity test that obtained a Cronbach alpha value of 0.86. RESULTS: The average behavior to prevent the risk of being exposed to COVID-19 before conducting a self-screening intervention in the intervention group was 1.92 (the behavior to prevent the risk of being exposed to COVID-19 was sufficient) and in the control group was 1.85 (the behavior to prevent the risk of being exposed to COVID-19 was sufficient) with p = 0.596 which means there is no difference in the average behavior to prevent the risk of being exposed to COVID-19, while after being given the self-screening intervention the average prevention behavior in the intervention group is 2.46 (the behavior to prevent the risk of being exposed to COVID-19 is good) and in the control group is 2.05 (the behavior of preventing the risk of being exposed to COVID-19 is good) with p = 0.000 which means that there is a difference in the average behavior of preventing the risk of being exposed to COVID-19 in the intervention group and the control group after being given a self-screening intervention. CONCLUSION: In general, this study proves that self-screening can foster behavior to prevent the risk of being exposed to COVID-19 in pregnant women.

Clinical Profile and Short-Term Outcome of SARS-CoV-2-Infected Neonates from a Government Medical College in West Bengal, India

INTRODUCTION

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has led to a terrifying global pandemic. The presentations in neonates are varied with less case severity compared to adults.

AIM

To describe the clinical and laboratory features and outcomes of neonates admitted with SARS-CoV-2 infection during the second surge of COVID-19 pandemic in a Government Medical College, West Bengal, India.

MATERIALS AND METHODS

It is a hospital-based observational cross-sectional study conducted in the newborn unit of Burdwan Medical College and Hospital between 1 April 2021 and 31 July 2021 including all SARS-CoV-2 Real time RT-PCR (Reverse transcriptase polymerase chain reaction) positive neonates. The demographic, clinical and laboratory characteristics of all the neonates and their outcomes were documented and analysed.

RESULTS

Twenty-two neonates were found to be SARS-CoV-2 RT-PCR positive out of which 9 (40.9%) were found to be asymptomatic and 6 (27.27%) required neonatal intensive care unit admissions. Among the symptomatic neonates, most common presentations were respiratory distress (40.9%) and gastrointestinal manifestations (40.9%). Eight (36.36%) neonates required respiratory support. Three (13.6%) neonates had pneumonia of which one had right middle lobe collapse. Laboratory parameters were nonspecific except for the two (9%) cases of multisystem inflammatory syndrome in neonates. High-resolution computed tomography findings in two cases were suggestive of SARS-CoV-2 infection-induced changes. Two (9%) neonates died of which one was likely due to SARS-CoV-2 infection.

CONCLUSION

Neonates with SARS-CoV-2 infection are mostly asymptomatic. However, clinicians must be vigilant as atypical presentations such as consolidation, collapse, meningitis or multisystem inflammatory syndrome may occur.

Multisystem inflammatory syndrome in neonates (MIS-N) associated with SARS-CoV2 infection: a case series

Multisystem inflammatory syndrome in neonates (MIS-N) is hypothesised to be caused either following transplacental transfer of SARS-CoV2 antibodies or antibodies developed in the neonate after infection with SARS-CoV-2. In this paper, we aim to discuss the clinical manifestations, laboratory features, and management of neonates diagnosed with MIS-N. We collated information from five participating hospitals in western India. A cohort of newborn infants presenting with multi-system involvement, along with the presence of SARS-CoV2 antibodies, was identified. Current proposed international diagnostic criteria for MIS-N were used to group the cases into three categories of Most likely, Possible, and Unlikely MIS-N. A total of 20 cases were reported with a diagnosis of MIS-N, all having high titres of SARS CoV2 IgG antibodies and negative for SARS CoV2 antigens. Most likely MIS (n = 5) cases presented with respiratory distress (4/5), hypotension and shock (4/5), and encephalopathy (2/5). Inflammatory markers like CRP (1/5), Procalcitonin (1/5), Ferritin (3/5), D-dimer (4/5), and LDH (2/5) were found to be elevated, and four of them had significantly high levels of proBNP. The majority of them (4/5) responded to immunomodulators, three neonates were discharged home, and two died. Possible MIS infants (n = 9) presented with fever (7/9), respiratory distress (4/9), refusal to feed (6/9), lethargy (5/9), and tachycardia (3/9). ProBNP as a marker of cardiac dysfunction was noted to be elevated in four (4/9) infants, correlating with abnormal echocardiography findings in two. In the Unlikely MIS (n = 6) category, three (3/6) infants presented with respiratory distress, one (1/6) with shock and cardiac dysfunction, and only one (1/6) with fever. All of them had elevated inflammatory markers. However, there were other potential diagnoses that could have been responsible for the clinical scenarios in these six cases.   Conclusion: MIS-N requires a high index of suspicion and should be considered in a neonate presenting with two or more systems involvement, in the presence of SARS-CoV2 antibodies, along with elevated inflammatory markers, once other common neonatal conditions have been ruled out. What is Known: • Severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) associated multisystem inflammatory syndrome in children (MIS-C) is  widely reported in paediatric population, however only few reports of newborn affection. • MIS-C is known to cause by virus-induced post-infective antibody mediated immune dysregulation with severe multi-system affection. What is New: • MIS-N may present with varied clinical manifestations with multi-system involvement of variable severity with milder disease in term and severe disease with cardiac dysfunction in preterm newborns. • Multisystem inflammatory syndrome in newborns (MIS-N) is postulated to occur following immune dysregulation associated with transplacental transfer of SARS-CoV2 antibodies or antibodies developed in the neonate after infection with SARS-CoV-2.

An observational study for appraisal of clinical outcome and risk of mother-to-child SARS-CoV-2 transmission in neonates provided the benefits of mothers' own milk

This observational study done during April-December 2020 at a tertiary-care hospital in Haryana (India) enrolled 152 SARS-CoV-2-exposed neonates. Among them, 150 neonates had perinatal SARS-CoV-2 exposure and 2 neonates had late postnatal exposure. Stable infant-mother dyads were roomed-in with precautions to support breastfeeding. Nasopharyngeal swabs collected from neonates were tested for SARS-CoV-2 by reverse transcriptase-polymerase chain reaction (RT-PCR) test. There was a high incidence of prematurity (23%), low birth weight (31%), intrauterine fetal distress (16%), perinatal asphyxia (6%), admission to neonatal intensive care unit (24%), and mortality (1.3%) among neonates with perinatal SARS-CoV-2 exposure. In this sub-group, 20 neonates tested positive for SARS-CoV-2 in nasopharyngeal swab sample(s). A recent official publication by the World Health Organization emphasizes that the perinatal SARS-CoV-2-exposed neonates found RT-PCR positive once in upper respiratory (non-sterile) sample must document viral persistence in another non-sterile sample for confirmation of mother-to-child virus transmission. With this approach, only one neonate was confirmed intrapartum transmission. A telephonic follow-up in discharged neonates at 1 month of age or 1 month postexposure recorded them all to be asymptomatic and doing well.Conclusion: Neonates with perinatal SARS-CoV-2 exposure constitute a high-risk group and it is not uncommon to get a positive RT-PCR report in upper respiratory sample(s) from these babies. Majority of them do not demonstrate viral persistence. Clinical outcomes are favorable in breastfed infants roomed-in with their asymptomatic-mild symptomatic SARS-CoV-2-infected mothers following appropriate safety protocols. What is Known: •Neonates with perinatal exposure suffer a high burden of morbidities and mortality. •Still, an uncertainty exists about rooming-in and breastfeeding among neonates born to SARS-CoV-2 positive mothers. What is New: •With the policy of mother-infant rooming-in and supporting breastfeeding, none of the neonate suffered clinical illness compatible with postnatal SARS-CoV-2 transmission and infection. •Around 13% perinatal exposed neonates demonstrated SARS-CoV-2 RNA in nasopharyngeal swab samples but the majority of them did not demonstrate viral persistence.

Clinical characteristics & outcome of SARS-CoV-2 infected neonates presenting to paediatric emergency

Background & objectives

Data on neonatal COVID-19 are limited to the immediate postnatal period, with a primary focus on vertical transmission in inborn infants. This study was aimed to assess the characteristics and outcome of COVID-19 in outborn neonates.

Methods

All neonates admitted to the paediatric emergency from August 1 to December 31, 2020, were included in the study. SARS-CoV-2 reverse transcription- (RT)-PCR test was done on oro/nasopharyngeal specimens obtained at admission. The clinical characteristics and outcomes of SARS-CoV-2 positive and negative neonates were compared and the diagnostic accuracy of a selective testing policy was assessed.

Results

A total of 1225 neonates were admitted during the study period, of whom SARS-CoV-2 RT-PCR was performed in 969. The RT-PCR test was positive in 17 (1.8%). Mean (standard deviation) gestation and birth weight of SARS-CoV-2-infected neonates were 35.5 (3.2) wk and 2274 (695) g, respectively. Most neonates (11/17) with confirmed COVID-19 reported in the first two weeks of life. Respiratory distress (14/17) was the predominant manifestation. Five (5/17, 29.4%) SARS-CoV-2 infected neonates died. Neonates with COVID-19 were at a higher risk for all-cause mortality [odds ratio (OR): 3.1; 95% confidence interval (CI): 1.1-8.9, P=0.03]; however, mortality did not differ after adjusting for lethal malformation (OR: 2.4; 95% CI: 0.7-8.7). Sensitivity, specificity, accuracy, positive and negative likelihood ratios (95% CI) of selective testing policy for SARS-CoV-2 infection at admission was 52.9 (28.5-76.1), 83.3 (80.7-85.6), 82.8 (80.3-85.1), 3.17 (1.98-5.07), and 0.56 (0.34-0.93) per cent, respectively.

Interpretation & conclusions

SARS-CoV-2 positivity rate among the outborn neonates reporting to the paediatric emergency and tested for COVID-19 was observed to be low. The selective testing policy had poor diagnostic accuracy in distinguishing COVID-19 from non-COVID illness.

Outcomes in neonates born to mothers with COVID-19 during the second wave in India

COVID-19 pandemic has affected all age groups globally including pregnant women and their neonates. The aim of the study was to understand outcomes in neonates of mothers with COVID-19 during the first and second waves of COVID-19 pandemic. A retrospective analysis of 2524 neonates born to SARS-CoV-2-infected mothers was conducted during the first wave (n = 1782) and second wave (n = 742) of the COVID-19 pandemic at five study sites of the PregCovid registry in Maharashtra, India. A significant difference was noted in preterm birth, which was higher in the second wave (15.0%, 111/742) compared to the first wave (7.8%, 139/1782) (P < 0.001). The proportion of neonates requiring NICU admission was significantly higher in the second wave (19.0%, 141/742) as compared to that in the first wave (14.8%, 264/1782) (P < 0.05). On comparing regional differences, significantly higher neonatal complications were reported from Mumbai metropolitan region (P < 0.05). During the second wave of COVID-19, birth asphyxia and prematurity were 3.8- and 2.1-fold higher respectively (P < 0.001). Neonatal resuscitation at birth was significantly higher in second wave (3.4%, 25/742 vs 1.8%, 32/1782) (P < 0.05). The prevalence of SARS-CoV-2 infection in neonates was comparable (4.2% vs 4.6%) with no significant difference between the two waves.

CONCLUSION

Higher incidence of adverse outcomes in neonates born to SARS-CoV-2-infected mothers in the second wave of COVID-19 as compared to the first wave.

TRIAL REGISTRATION

PregCovid study is registered with the Clinical Trial Registry of India (CTRI/2020/05/025423, Registered on 28/05/2020).

WHAT IS KNOWN

• The second wave of COVID-19 was more lethal to pregnant women than the first wave. Newborns are at risk of developing complications.

WHAT IS NEW

• Birth asphyxia, prematurity, and neonatal resuscitation at birth were significantly higher in the second wave as compared to those in the first wave of the COVID-19 pandemic in India.

Emergency Peripartum Hysterectomy During COVID-19 Pandemic

Objective

To evaluate women undergoing emergency peripartum hysterectomy (EPH) during COVID-19 pandemic regarding their sociodemographic features, indications, intraoperative and postoperative complications, and assess their health problems related to a traumatic birth.

Methods

This was a retrospective review of EPH cases operated from March 2020 to March 2021 in terms of demographic characteristics, intraoperative, and postoperative outcome variables.

Results

During the specified time period, there were nine cases of EPH. All patients were young with ages ranging from 25 to 31 years; all were unbooked having unplanned pregnancies and presented at varying gestational ages. Six out of nine cases (66.67%) had previously scarred uterus with five women having morbidly adhered placenta. A total of 77.78% (seven out of nine) patients referred to our centre with high-risk factors. Five out of nine women (55.56%) needed ICU care. Seven out of nine women (77.78%) had live births and two of these infants died. The guilt of losing the baby, lethargy, worries related to feminity and sexual health, and flashbacks of ICU stay were major concerns.

Conclusion

The morbidly adhered placenta was the primary cause of EPH in our study cohort. Preventive psychological session should be an integral part of postpartum follow-up visits for any women with traumatic childbirth.

Clinical and epidemiological characterization in the follow-up of newborns with COVID-19: a descriptive study

Introduction

COVID-19 disease affects newborns, but its middle and long-term effects are still unclear.

Objective

To describe the clinical and epidemiological characteristics and follow-up of newborns infected with SARS-CoV-2.

Methods

An observational and descriptive study. We included newborns with SARS-CoV-2 positive RT-PCR born from SARS-CoV-2 seropositive mothers. Delivery and newborn care were provided at the 'Instituto Nacional Materno Perinatal' from Peru between June 1 and September 30, 2020. Perinatal information was collected from medical records. Remote follow-up and face-to-face evaluations gathered epidemiological and clinical information, in addition to serological and RT-PCR tests for SARS-CoV-2. Descriptive statistics were used for analysis.

Results

During the study period, 4733 neonates were born at the institution. We found that 1488 (31.4%) were born from seropositive for SARS-CoV-2 mothers. Finally, we included the 34 (2.3%) newborns with positive RT-PCR for SARS-CoV-2. Regarding the included newborns, 29.4% were delivered by cesarean section, 26.5% had low birth weight, 11.8% were preterm, 26.5% were hospitalized, and one died. Twenty-eight had a remote follow-up, and 18 also had a face-to-face follow-up. A total of 64.3% were exclusively breastfed, 28.6% were mixed breastfed, and 7.1% used a substitute formula. The face-to-face evaluation was performed between one and four months of chronological age. We found that 100% had negative control RT-PCR test for COVID-19, 38.9% had a negative serological test (IgM, IgG), and 61.1% positive IgG.

Conclusions

Neonatal SARS-CoV-2 infection is rare, and most infected infants are asymptomatic. Vaginal delivery, breastfeeding, and joint isolation did not related with complications during hospital care. Infants under remote and in-person follow-up showed favorable clinical evolution during the study period.

A comprehensive review on efficient approaches for combating coronaviruses

Almost 80% of people confronting COVID-19 recover from COVID-19 disease without any particular treatments. They experience heterogeneous symptoms; a wide range of respiratory symptoms, cough, dyspnea, fever, and viral pneumonia. However, some others need urgent intervention and special treatment to get rid of this widespread disease. So far, there isn't any unique drug for the potential treatment of COVID 19. However, some available therapeutic drugs used for other diseases seem beneficial for the COVID-19 treatment. On the other hand, there is a robust global concern for developing an efficient COVID-19 vaccine to control the COVID-19 pandemic sustainably. According to the WHO report, since 8 October 2021, 320 vaccines have been in progress. 194 vaccines are in the pre-clinical development stage that 126 of them are in clinical progression. Here, in this paper, we have comprehensively reviewed the most recent and updated information about coronavirus and its mutations, all the potential therapeutic approaches for treating COVID-19, developed diagnostic systems for COVID- 19 and the available COVID-19 vaccines and their mechanism of action.

Adherence of Clinical Practice Guidelines for Pharmacologic Treatments of Hospitalized Patients With COVID-19 to Trustworthy Standards: A Systematic Review

IMPORTANCE

The COVID-19 pandemic created the need for rapid and urgent guidance for clinicians to manage COVID-19 among patients and prevent transmission.

OBJECTIVE

To appraise the quality of clinical practice guidelines (CPGs) using the National Academy of Medicine (NAM) criteria.

EVIDENCE REVIEW

A search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials to December 14, 2020, and a search of related articles to February 28, 2021, that included CPGs developed by societies or by government or nongovernment organizations that reported pharmacologic treatments of hospitalized patients with COVID-19. Teams of 2 reviewers independently abstracted data and assessed CPG quality using the 15-item National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) instrument.

FINDINGS

Thirty-two CPGs were included in the review. Of these, 25 (78.1%) were developed by professional societies and emanated from a single World Health Organization (WHO) region. Overall, the CPGs were of low quality. Only 7 CPGs (21.9%) reported funding sources, and 12 (37.5%) reported conflicts of interest. Only 5 CPGs (15.6%) included a methodologist, described a search strategy or study selection process, or synthesized the evidence. Although 14 CPGs (43.8%) made recommendations or suggestions for or against treatments, they infrequently rated confidence in the quality of the evidence (6 of 32 [18.8%]), described potential benefits and harms (6 of 32 [18.8%]), or graded the strength of the recommendations (5 of 32 [15.6%]). External review, patient or public perspectives, or a process for updating were rare. High-quality CPGs included a methodologist and multidisciplinary collaborations involving investigators from 2 or more WHO regions.

CONCLUSIONS AND RELEVANCE

In this review, few COVID-19 CPGs met NAM standards for trustworthy guidelines. Approaches that prioritize engagement of a methodologist and multidisciplinary collaborators from at least 2 WHO regions may lead to the production of fewer, high-quality CPGs that are poised for updates as new evidence emerges.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42021245239.

Update to Perinatal-Neonatal Management of COVID-19 Guidelines

The guidelines for diagnosing and managing perinatal SARS-CoV-2 infection for the Indian context were last updated in May 2020. Newer evidence, the evolution of the pandemic, and its significant impact on mother-infant dyads led us to review and revise the guideline. This article summarizes the salient changes in the perinatal-neonatal management of COVID-19.

Breastfeeding in Coronavirus Disease 2019 (COVID-19): Position Statement of Indian Academy of Pediatrics and Infant and Young Child Feeding Chapter

Justification

Recent research has provided evidence for lack of transmission of SARS-CoV-2 through human milk and breastfeeding. Updating the practice guidelines will help in providing appropriate advice and support regarding breastfeeding during the coronavirus 2019 (COVID-19) pandemic.

Objectives

To provide evidence-based guidelines to help the healthcare professionals to advise optimal breastfeeding practices during the COVID-19 pandemic.

Process

Formulation of key questions was done under the chairmanship of President of the IAP. It was followed by review of literature and the recommendations of other international and national professional bodies. Through Infant and Young child (IYCF) focused WhatsApp group opinion of all members was taken. The final document was prepared after the consensus and approval by all members of the committee.

Recommendations

The IYCF Chapter of IAP strongly recommends unabated promotion, protection and support to breastfeeding during the COVID-19 pandemic with due precautions.

Assessment of health equity consideration in masking/PPE policies to contain COVID-19 using PROGRESS-plus framework: a systematic review

INTRODUCTION

There is increasing evidence that COVID-19 has unmasked the true magnitude of health inequity worldwide. Policies and guidance for containing the infection and reducing the COVID-19 related deaths have proven to be effective, however the extent to which health inequity factors were considered in these policies is rather unknown. The aim of this study is to measure the extent to which COVID-19 related policies reflect equity considerations by focusing on the global policy landscape around wearing masks and personal protection equipment (PPE).

METHODS

A systematic search for published documents on COVID-19 and masks/PPE was conducted across six databases: PubMed, EMBASE, CINAHL, ERIC, ASSIA and Psycinfo. Reviews, policy documents, briefs related to COVID-19 and masks/PPE were included in the review. To assess the extent of incorporation of equity in the policy documents, a guidance framework known as 'PROGRESS-Plus': Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, Plus (age, disability etc.) was utilized.

RESULTS

This review included 212 policy documents. Out of 212 policy documents, 190 policy documents (89.62%) included at least one PROGRESS-plus component. Most of the policy documents (n = 163, 85.79%) focused on "occupation" component of the PROGRESS-plus followed by personal characteristics associated with discrimination (n = 4;2.11%), place of residence (n = 2;1.05%) and education (n = 1;0.53%). Subgroup analysis revealed that most of the policy documents (n = 176, 83.01%) were focused on "workers" such as healthcare workers, mortuary workers, school workers, transportation workers, essential workers etc. Of the remaining policy documents, most were targeted towards whole population (n = 30; 14.15%). Contrary to "worker focused" policy documents, most of the 'whole population focused' policy documents didn't have a PROGRESS-plus equity component rendering them equity limiting for the society.

CONCLUSION

Our review highlights even if policies considered health inequity during the design/implementation, this consideration was often one dimensional in nature. In addition, population wide policies should be carefully designed and implemented after identifying relevant equity related barriers in order to produce better outcomes for the whole society.

Shock and dyselectrolytemia in a neonate with late-onset COVID-19 infection

Most reports of COVID-19 in neonates suggest that they are infected postnatally and present with gastrointestinal or respiratory symptoms. We describe a neonate who had community-acquired COVID-19, and presented with late-onset sepsis and developed dyselectrolytemia. The 26-day-old male baby had fever, feed refusal and shock. Rapid antigen test for SARS-CoV-2 by nasopharyngeal swab was positive and levels of circulating inflammatory markers were high. The baby was supported with antibiotics, and inotropic and vasopressor drugs. He had seizures and bradycardia due to dyselectrolytemia on day 2 of admission. On day 3, he had respiratory distress, with non-specific chest radiographic findings, and was managed with non-invasive support for 24 hours. The baby was discharged after 8 days. On serial follow-up, he was breastfeeding well and gaining weight appropriately with no morbidity. Our report highlights a unique presentation of COVID-19, with late-onset infection and shock-like features along with dyselectrolytemia and seizures.

Outcome of Neonates Born to COVID-Positive Women at 6 Months of Age

Objective

Methods

Results

Conclusions

Delivery management of suspected or confirmed COVID-19 positive mothers

The Coronavirus Disease-2019 (COVID-19) pandemic has brought catastrophic impact on the world since the beginning of December 2019. Extra precautionary measures against COVID-19 during and after delivery are pivotal to ensure the safety of the baby and health care workers. Based on current literature, it is recommended that delivery decisions be discussed between obstetricians and neonatologists prior to delivery, and designated negative pressure delivery rooms should be arranged for COVID person under investigation (PUI). During delivery, a minimal number of experienced staff attending delivery should don personal protective equipment (PPE) and follow the neonatal resuscitation program (NRP). Positive pressure ventilation is best used in a negative pressure room if available. At-risk babies should be transported in an isolette, and tested for COVID-19 in a negative pressure room soon after bathing. Skin-to-skin contact and breast milk feed should continue under certain circumstances. Although newborns with COVID-19 infections often present with symptoms that mimic sepsis and one third of affected patients may demand some form of respiratory support, short-term prognoses are favorable and most recover within two weeks of symptoms onset. In this article, we will further elaborate on topics covering timing and mode of delivery, antenatal steroid, vertical transmission, delivery room management, airway management, transport, testing and isolation after birth, skin-to-skin contact, breast milk feeding, clinical features, outcomes, and discharge plans. In addition, we also share our experiences of encountering neonates born of suspected COVID-19 positive mothers.

Preparedness for Pediatric COVID-19 Using Systems Approach: Experience of a Health Care Facility from India

A pandemic leads to disruption and stretching of an existing health care system and its resources. Coronavirus disease 2019 (COVID-19) data show distinct and severe manifestations in children necessitating critical care. Children need prioritization as they are susceptible to COVID-19 as part of the family cluster, varied presentations, and mortality. The purpose of this report is to discuss the optimization of the health care system for pediatric care. The key initiatives were to identify our objectives, bring out changes to the organizational processes, and integrate the same into the existing system. A systems approach to health care delivery by optimizing infrastructure, human resources, materials, funding, leadership, and governance was undertaken. This resulted in creation of distinct COVID-19 and non-COVID-19 service areas, management protocols, and trained health care workers. Partnership was forged with the public health system. This preparedness and continued responses to the demands of the health care system helped us manage children ranging from neonates to adolescents efficiently. Though the health care system is mostly open, acting upon the modifiable factors gave better preparedness in a short time.

Clinical Features and Outcome of SARS-CoV-2 Infection in Neonates: A Systematic Review

OBJECTIVE

The objective of this study is to systematically synthesize the currently available literature on various modes of transmission (congenital, intrapartum, and postpartum), clinical features and outcomes of SARS-CoV-2 infection in neonates.

METHODS

We conducted a comprehensive literature search using PubMed, EMBASE, and Web of Science until 9 June 2020. A combination of keywords and MeSH terms, such as COVID-19, coronavirus, SARS-CoV-2, 2019-nCoV, severe acute respiratory syndrome coronavirus 2, neonates, newborn, infant, pregnancy, obstetrics, vertical transmission, maternal-foetal transmission and intrauterine transmission, were used in the search strategy. We included studies reporting neonatal outcomes of SARS-CoV-2 proven pregnancies or neonatal cases diagnosed with SARS-CoV-2 infection.

RESULTS

Eighty-six publications (45 case series and 41 case reports) were included in this review. Forty-five case series reported 1992 pregnant women, of which 1125 (56.5%) gave birth to 1141 neonates. A total of 281 (25%) neonates were preterm, and caesarean section (66%) was the preferred mode of delivery. Forty-one case reports describe 43 mother-baby dyads of which 16 were preterm, 9 were low birth weight and 27 were born by caesarean section. Overall, 58 neonates were reported with SARS-CoV-2 infection (4 had a congenital infection), of which 29 (50%) were symptomatic (23 required ICU) with respiratory symptoms being the predominant manifestation (70%). No mortality was reported in SARS-CoV-2-positive neonates.

CONCLUSION

The limited low-quality evidence suggests that the risk of SARS-CoV-2 infections in neonates is extremely low. Unlike children, most COVID-positive neonates were symptomatic and required intensive care. Postpartum acquisition was the commonest mode of infection in neonates, although a few cases of congenital infection have also been reported.

Neonatal Multisystem Inflammatory Syndrome (MIS-N) Associated with Prenatal Maternal SARS-CoV-2: A Case Series

Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious immune-mediated condition, seen 3-5 weeks after COVID-19. Maternal SARS-CoV-2 may potentially cause a similar hyperinflammatory syndrome in neonates due to transplacental transfer of antibodies. We reviewed the perinatal history, clinical features, and outcomes of 20 neonates with features consistent with MIS-C related to maternal SARS-CoV-2 in Kolhapur, India, from 1 September 2020 to 30 April 2021. Anti-SARS-CoV-2 IgG and IgM antibodies were tested in all neonates. Fifteen singletons and five twins born to eighteen mothers with a history of COVID-19 disease or exposure during pregnancy presented with features consistent with MIS-C during the first 5 days after birth. Nineteen were positive for anti-SARS-CoV-2 IgG and all were negative for IgM antibodies. All mothers were asymptomatic and therefore not tested by RTPCR-SARS-CoV-2 at delivery. Eighteen neonates (90%) had cardiac involvement with prolonged QTc, 2:1 AV block, cardiogenic shock, or coronary dilatation. Other findings included respiratory failure (40%), fever (10%), feeding intolerance (30%), melena (10%), and renal failure (5%). All infants had elevated inflammatory biomarkers and received steroids and IVIG. Two infants died. We speculate that maternal SARS-CoV-2 and transplacental antibodies cause multisystem inflammatory syndrome in neonates (MIS-N). Immunomodulation may be beneficial in some cases, but further studies are needed.

Perinatal outcome and possible vertical transmission of coronavirus disease 2019: experience from North India

BACKGROUND

The consequences of severe acute respiratory syndrome corona virus 2 on mother and fetus remain unknown due to a lack of robust evidence from prospective studies.

PURPOSE

This study evaluated the effect of coronavirus disease 2019 (COVID-19) on neonatal outcomes and the scope of vertical transmission.

METHODS

This ambispective observational study enrolled pregnant women with COVID-19 in North India from April 1 to August 31, 2020 to evaluate neonatal outcomes and the risk of vertical transmission.

RESULTS

A total of 44 neonates born to 41 COVID-19-positive mothers were evaluated. Among them, 28 patients (68.3%) (2 sets of twins) were delivered within 7 days of testing positive for COVID-19, 23 patients (56%) (2 sets of twins) were delivered by cesarean section; 13 newborns (29.5%) had low birth weight; 7 (15.9%) were preterm; and 6 (13.6%) required neonatal intensive care unit admission, reflecting an increased incidence of cesarean delivery and low birth weight but zero neonatal mortality. Samples of cord blood, placental membrane, vaginal fluid, amniotic fluid, peritoneal fluid (in case of cesarean section), and breast milk for COVID-19 reverse transcription-polymerase chain reaction tested negative in 22 prospective delivery cases. Nasopharyngeal swabs of 2 newborns tested positive for COVID-19: one at 24 hours and the other on day 4 of life. In the former case, biological samples were not collected as the mother was asymptomatic and her COVID-19 report was available postdelivery; hence, the source of infection remained inconclusive. In the latter case, all samples tested negative, ruling out the possibility of vertical transmission. All neonates remained asymptomatic on follow-up.

CONCLUSION

COVID-19 does not have direct adverse effects on the fetus per se. The possibility of vertical transmission is almost negligible, although results from larger trials are required to confirm our findings.

Assessment of knowledge and opinion regarding breastfeeding practices during COVID-19 pandemic among paediatricians and obstetricians in India: an online survey

Coronavirus disease 19 (COVID-19) is a novel coronavirus infection that has a wide spectrum of disease severity. The virus has not been known to pass through the placenta and has not been reported in the breastmilk of affected mothers. As the cases are still on a rise, it is expected that the number of pregnant females would also rise in the coming times. Among many queries during pregnancy, to breastfeed or not is an important question that needs to be answered. We conducted this survey to assess the knowledge regarding breastfeeding practices among Indian paediatricians and obstetricians during the COVID-19 pandemic. An online survey was conducted among paediatricians and obstetricians from all over India. Only 294 (54.1%) participants have adequate knowledge regarding breastfeeding recommendations. The gap in knowledge between paediatricians and obstetricians was found statistically significant with a p value of <0.01. Only 30% healthcare providers associated with perinatal care received this information through a seminar. On the other hand, 15% of participants were not aware of any guidelines on breastfeeding during the COVID-19 pandemic. More rigorous dissemination of information on breastfeeding practices in COVID-19 case management needs to be adopted.

COVID-19 guidelines for pregnant women and new mothers: A systematic evidence review

BACKGROUND

Nearly a year after COVID-19 was initially detected, guidance for pregnant and new mothers remains varied.

OBJECTIVE

The goal of this systematic review is to summarize recommendations for three areas of maternal and fetal care-breastfeeding, post-partum social distancing, and decontamination.

SEARCH STRATEGY

We searched PubMed, Embase and Web of Science spanning from inception to November 9, 2020.

SELECTION CRITERIA

Articles were included if they focused on COVID-positive mothers, commented on at least one of the three areas of interest, and were published in English.

DATA COLLECTION AND ANALYSIS

Our combined database search yielded 385 articles. After removing duplicates and articles that did not cover the correct populations or subject matter, a total of 74 articles remained in our analysis.

MAIN RESULTS

Most articles recommended direct breastfeeding with enhanced precaution measures. Recommendations regarding post-partum social distancing varied, although articles published more recently often recommended keeping the mother and newborn in the same room when possible. Decontamination recommendations emphasized mask wearing, good hand hygiene, and proper cleaning of surfaces.

CONCLUSION

In general, there was a focus on shared decision making when approaching topics such as breastfeeding and post-partum social distancing. Guidelines for decontamination were fairly uniform.

Outcomes of Neonates Born to Mothers With Coronavirus Disease 2019 (COVID-19) — National Neonatology Forum (NNF) India COVID-19 Registry

Background

Limited evidence exists on perinatal transmission and outcomes of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in neonates.

Objective

To describe clinical outcomes and risk factors for transmission in neonates born to mothers with perinatal SARS-CoV-2 infection.

Design

Prospective cohort of suspected and confirmed SARS-CoV-2 infected neonates entered in National Neonatology Forum (NNF) of India registry.

Subjects

Neonates born to women with SARS-CoV-2 infection within two weeks before or two days after birth and neonates with SARS-CoV-2 infection.

Outcomes

Incidence and risk factors of perinatal transmission.

Results

Among 1713 neonates, SARS-CoV-2 infection status was available for 1330 intramural and 104 extramural neonates. SARS-CoV-2 positivity was reported in 144 intramural and 39 extramural neonates. Perinatal transmission occurred in 106 (8%) and horizontal transmission in 21 (1.5%) intramural neonates. Neonates roomed-in with mother had higher transmission risk (RR1.16, 95% CI 1.1 to 2.4; P=0.01). No association was noted with the mode of delivery or type of feeding. The majority of neonates positive for SARS-CoV2 were asymptomatic. Intramural SARS-CoV-2 positive neonates were more likely to be symptomatic (RR 5, 95%CI 3.3 to 7.7; P<0.0001) and need resuscitation (RR 2, 95%CI 1.0 to 3.9; P=0.05) compared to SARS-CoV-2 negative neonates. Amongst symptomatic neonates, most morbidities were related to prematurity and perinatal events.

Conclusion

Data from a large cohort suggests perinatal transmission of SARS-CoV-2 infection and increased morbidity in infected infants.

Sniffer dogs as a screening/diagnostic tool for COVID-19: a proof of concept study

BACKGROUND

Sniffer dogs are able to detect certain chemical particles and are suggest to be capable of helping diagnose some medical conditions and complications, such as colorectal cancer, melanoma, bladder cancer, and even critical states such as hypoglycemia in diabetic patients. With the global spread of COVID-19 throughout the world and the need to have a real-time screening of the population, especially in crowded places, this study aimed to investigate the applicability of sniffer dogs to carry out such a task.

METHODS

Firstly, three male and female dogs from German shepherd (Saray), German black (Kuzhi) and Labrador (Marco) breeds had been intensively trained throughout the classical conditioning method for 7 weeks. They were introduced to human specimens obtained from the throat and pharyngeal secretions of participants who were already reported positive or negative for SARS-COV-2 infection be RT-PCR. Each dog underwent the conditioning process for almost 1000 times. In the meantime another similar condition process was conducted on clothes and masks of COVID-19 patient using another three male and female dogs from Labrador (Lexi), Border gypsy (Sami), and Golden retriever (Zhico) breeds. In verification test for the first three dogs, 80 pharyngeal secretion samples consisting of 26 positive and 54 negative samples from different medical centers who underwent RT-PCR test were in a single-blind method. In the second verification test for the other three dogs, masks and clothes of 50 RT-PCR positive and 70 RT-PCR negative cases from different medical center were used.

RESULTS

In verification test using pharyngeal secretion, the sniffer dogs' detection capability was associated with a 65% of sensitivity and 89% of specificity and they amanged to identify 17 out of the 26 positive and 48 out of the 54 true negative samples. In the next verification test using patients' face masks and clothes, 43 out of the 50 positive samples were correctly identified by the dogs. Moreover, out of the 70 negative samples, 65 samples were correctly found to be negative. The sensitivity of this test was as high as 86% and its specificity was 92.9%. In addition, the positive and negative predictive values were 89.6 and 90.3%, respectively.

CONCLUSION

Dogs are capable of being trained to identify COVID-19 cases by sniffing their odour, so they can be used as a reliable tool in limited screening.

SARS-CoV-2 detection in human milk: a systematic review

PURPOSE

To synthesize the current evidence for the presence of SARS-CoV-2 RNA in the human milk of mothers with confirmed COVID-19 and its potential role in neonatal SARS-CoV-2 infection.

MATERIALS AND METHODS

Using terms related to novel coronavirus 2019 and human milk, a systematic search was performed in three electronic databases (PubMed, EMBASE, and Web of Science) for studies published between December 2019 and 15 October 2020. Published peer-reviewed studies reporting the results of RT-PCR for SARS-CoV-2 RNA in human milk in mothers with confirmed COVID-19 were included. Proportion meta-analysis of case series and prospective cohort studies was performed using STATA version 14.2 (StataCorp, College Station, TX) and pooled estimate (with 95% confidence interval) of overall incidence of SARS-CoV-2 transmission was calculated.

RESULTS

We identified 936 records, of which 34 studies (24 case-reports, 10 cohort studies) were eligible for this systematic review. A total of 116 confirmed COVID-19 lactating women (88 in cohort and 28 in case-reports) underwent RT-PCR testing in human milk, and 10 (six in case reports) were detected to have SARS-CoV-2 RNA. The overall pooled proportion (from cohort studies) for SARS-CoV-2 RNA detection in human milk was 2.16% (95% CI: 0.0-8.81%, I ²: 0%). Four studies (six patients) also reported the presence of SARS-CoV-2 specific antibodies (along with RT-PCR) in human milk.

CONCLUSIONS

The limited low-quality evidence suggests that SARS-CoV-2 RNA is detected in human milk in an extremely low proportion, however, based on current evidence no conclusion can be drawn about its infectivity and impact on the infants. In concordance with World Health Organization recommendations, exclusive breastfeeding should be considered in all cases unless any other contraindication exists.

Clinical profile, viral load, management and outcome of neonates born to COVID 19 positive mothers: a tertiary care centre experience from India

Despite rapidly evolving knowledge about COVID 19 infection, routes of perinatal COVID 19 transmission and viral load in mother neonate dyad remain uncertain. Data were analysed to describe the clinicodemographic profile and viral load in neonates born to COVID 19 positive mothers. Of 2947 deliveries, 69 mothers were COVID 19 positive (2.3%), with 1 abortion, 2 macerated stillbirths and 2 fresh stillbirths as pregnancy outcomes. Of 65 tested neonates, 10.7% (7) were confirmed COVID 19 positive by RTPCR (reverse transcriptase-polymerase chain reaction). Viral load (cycle threshold, Ct of E, RDRp) in neonates was comparable with the Ct reported from adults; however, neonates had milder clinical manifestations. All 7 neonates who tested positive for COVID 19 were subsequently discharged. Six of the 7 neonates were asymptomatic and 1 neonate needed respiratory support (indication being prematurity) which resolved after 48 h. Maternal and neonatal comparison of Ct of E and RdRp gene was statistically non-significant (25.97 vs 19.68, p = 0.34 and 26.5 vs 25.0, p = 0.84). Viral loads of mothers with COVID 19 positive neonates compared with mothers with COVID 19 negative neonates for E and RdRp gene were also statistically non-significant (25 vs 27.19, p = 0.63 and 19.6 vs 27.6, p = 0.08). The majority (93%) of neonates tested later than 48 h (roomed in with mother and breastfed) tested negative.Conclusion: The study supports milder manifestation in COVID 19 positive neonates. Risk of transmission from COVID 19 positive mother to neonate by rooming-in and breastfeeding is low. In this study on a limited number of neonates, maternal viral load was not found to be associated with the positivity status or severity of the illness of neonate. What is Known: • Neonates born to COVID 19 positive mothers are at risk of COVID 19 infection. What is New: • Risk of transmission of COVID 19 from mother to neonate, with rooming-in and breastfeeding, appears low. • In this study on a limited number of neonates, maternal viral load of COVID 19 (E and RdRp cycle thresholds) was not associated with severity of illness or COVID 19 positivity in neonates.

A single-center observational study on clinical features and outcomes of 21 SARS-CoV-2-infected neonates from India

Coronavirus disease-19 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is an ongoing pandemic with significant morbidity and mortality. Neonates represent a vulnerable population, in which we have limited knowledge of its natural history, optimal management, and outcomes. In this retrospective observational study from a low-middle-income setting, clinical characteristics and outcomes of neonatal SARS-CoV-2 infection were evaluated. We report an incidence of 10.6% of SARS-CoV-2 infection (21 neonates), among a group of 198 neonates with suspected infection. Most of the SARS-CoV-2-infected neonates were term (80.9%) and none required any resuscitation. The infection was detected by a positive nasopharyngeal swab reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV-2. Neonatal COVID-19 manifestations developed in one-third (33.3%) of the infected neonates. Most of them demonstrated the involvement of respiratory (33.3%) and gastrointestinal systems (4.8%). Laboratory parameters suggested multi-systemic involvement, with elevated creatine kinase (CK) (76.2%), creatine kinase-myocardial band (CK-MB) (76.2%), and lactate dehydrogenase (LDH) (71.4%) levels. Supportive treatment was given to infected neonates with intensive care required in six neonates (28.6%). This included four preterm and two term neonates, of which two received non-invasive and one received invasive ventilation with intra-tracheal surfactant instillation. IgM antibodies against COVID-19 were detected in one neonate. All neonates with COVID-19 improved and were successfully discharged.Conclusion: SARS-CoV-2 in neonates has a wide clinical spectrum. Further studies are needed which are adequately powered to completely understand the course of this infection in neonates, its implications not only in the neonatal period but also on long-term follow-up. What is Known: • SARS-CoV-2 infection has a predilection for all age groups but with limited literature on clinical profile, outcomes, and long-term follow-up in neonates. What is New: • SARS-CoV-2 infection in neonates has a wide clinical spectrum and displays a significant overlap with common neonatal conditions. • Most neonates with COVID-19 improved with supportive care, though a subset required intensive care, emphasizing the need for cautious monitoring and management.

Maternal Transmission of SARS-CoV-2: Safety of Breastfeeding in Infants Born to Infected Mothers

Coronavirus disease 2019 (COVID-19) is a recent epidemic disease caused by severe acute respiratory syndrome virus type 2 (SARS-CoV-2). In pregnancy, SARS-Cov-2 infection creates additional alarm due to concerns regarding the potential for transmission from the mother to the baby during both the antenatal and postpartum times. In general, breastfeeding is seldom disallowed because of infection of the mother. However, there are few exceptions with regards to certain infectious organisms with established transmission evidence from mother to infant and the link of infection of a newborn with significant morbidity and mortality. It is confirmed that pregnant women can become infected with SARS-CoV-2, although the debate on the possible vertical transmission of SARS-CoV-2 infection during pregnancy is still open. In this regard, the literature is still poor. On the contrary, the information on the safety of breastfeeding even during infections seems reassuring when the mother takes the necessary precautions. However, there are still answered questions regarding the precautions to be taken during breastfeeding by COVID-19 patients. This paper reviews the existing answers to these and many other questions. This review therefore presents a summary of the present-day understanding of infection with SARS-CoV-2 and discusses the answers around the maternal transmission of COVID-19 and the potential threat of breastfeeding to babies born to infected pregnant mothers. In conclusion, intrauterine transmission of SARS-CoV-2 infection is less likely to occur during pregnancy. Most studies suggest that COVID-19 is not transmitted through breast milk. Correspondingly, COVID-19-infected neonates might acquire the infection via the respiratory route because of the postnatal contact with the mother rather than during the prenatal period. International organizations encourage breastfeeding regardless of the COVID-19 status of the mother or child as long as proper hygienic and safety measures are adhered to so as to minimize the chance of infant infection by droplets and direct contact with the infected mother. Pasteurized donor human milk or infant formula as supplemental feeding can be quite beneficial in the case of mother-infant separation till breastfeeding is safe.

Disposable low-cost cardboard incubator for thermoregulation of stable preterm infant - a randomized controlled non-inferiority trial

BACKGROUND

Incubators and radiant warmers are essential equipment in neonatal care, but the typical 1,500 to 35,000 USD cost per device makes it unaffordable for many units in low and middle-income countries. We aimed to determine whether stable preterm infants could maintain thermoregulation for 48 h in a low-cost incubator (LCI).

METHODS

The LCI was constructed using a servo-heater costing 200 USD and cardboard infant-chamber. We conducted this open-labeled non-inferiority randomized controlled trial in a tertiary level teaching hospital in India from May 2017 to March 2018. Preterm infants on full feeds and receiving incubator or radiant warmer care were enrolled at 32 to 36 weeks post-menstrual age. We enrolled 96 infants in two strata (Strata-1< 33 weeks, Strata-2 ≥ 33 weeks at birth). Infants were randomized to LCI or standard single-wall incubator (SSI) after negative incubator cultures and monitored for 48 h in air-mode along with kangaroo mother care. The incubator temperature was adjusted manually to maintain skin and axillary temperatures between 36.5 °C and 37.5 °C. During post-infant period after 48 h, SSI and LCI worked for 5 days and incubator temperatures were measured. The primary outcome was maintenance of skin and axillary temperatures with a non-inferiority margin of 0.2 °C. Failed thermoregulation was defined as abnormal axillary temperature (< 36.5 °C or >37.5 °C) for > 30 continuous-minutes. Secondary outcomes were incidence of hypothermia and required incubator temperature. Trial registration details: Clinical Trial Registry - India (CTRI/2015/10/006316).

FINDINGS

Prior to enrollment 79(82%) infants were in radiant warmer and 17(18%) infants were in incubator care. Median weight at enrollment in Strata-1 and Strata-2 for SSI vs. LCI was 1355(IQR 1250-1468) vs. 1415(IQR 1280-1582) and 1993(IQR 1595-2160) vs. 1995(IQR 1632-2237) grams. Mean skin temperature in Strata-1 and Strata-2 for SSI vs. LCI was 36.8 °C ± 0.2 vs. 36.7 °C ± 0.18 and 36.8 °C ± 0.22 vs. 36.7 °C ± 0.19. Mean axillary temperature in Strata-1 and Strata-2 for SSI vs. LCI was 36.9 °C ± 0.19 vs. 36.8 °C ± 0.16 and 36.8 °C ± 0.2 vs. 36.8 °C ± 0.19. Mixed-effect model done for repeated measures of skin and axillary temperatures showed the estimates were within the non-inferiority limit; -0.07 °C (95% CI -0.11 to -0.04) and -0.06 °C (95% CI -0.095 to -0.02), respectively. Failed thermoregulation did not occur in any infants. Mild hypothermia occurred in 11 of 48(23%) of SSI and 16 of 48(33%) of LCI, OR 1.28 (95%CI 0.85 to 1.91). Incubator temperature in LCI was higher by 0.7 °C (95%CI 0.52 to 0.91). In the post-infant period SSI and LCI had excellent reliability to maintain set-temperature with intra-class correlation coefficient of 0.93 (95%CI 0.92 to 0.94) and 0.96 (95%CI 0.96 to 0.97), respectively.

INTERPRETATION

Maintenance of skin and axillary temperature of stable preterm infants in LCI along with kangaroo mother care was non-inferior to SSI, but at a higher incubator temperature by 0.7 °C. No adverse events occurred and LCI had excellent reliability to maintained set-temperature.

FUNDING

Food and Drug Administration (Award number P50FD004895).