Multisystem inflammatory disease in neonates (MIS-N) due to maternal COVID-19.

Multisystem inflammatory disease in neonates (MIS-N) is a disease of immune dysregulation presenting in the newborn period. Thouvgh its etiopathogenesis is proposed to be similar to multisystem inflammatory disease in Children (MIS-C), the exact pathophysiology is largely unknown as of present. The definition of MIS-N is contentious. The evidence for its incidence, the clinical features, profile of raised inflammatory markers, treatment strategies and outcomes stem from case reports, case series and cohort studies with small sample sizes. Though the incidence of MIS-N in severe acute respiratory syndrome caused by the coronavirus CoVID-2 (SARS-CoV-2) infected asymptomatic neonates is low, its incidence in symptomatic neonates is relatively higher. Further, amongst the neonates who are treated as MIS-N, the mortality rate is high. The review also evaluates the various other unresolved aspects of MIS-N from limited published literature and identifies knowledge gaps which could be areas of future research.

Clinical features of neonatal COVID-19

The COVID-19 (SARS-Cov-2) pandemic has put a strain on healthcare systems around the world from December 2019 in China, and then rapidly spreading worldwide. The impact of the virus on the entire population and its differential effect on various age groups was unknown at the outset, specifically its severity in elders, children or those living with other comorbidities, thus defining the syndemic, rather than pandemic, character of the infection. The effort of clinicians was initially to organize differential paths to isolate cases or contacts. This impacted the maternal-neonatal care adding an additional burden to this dyad and raising several questions. Can SARS-Cov-2 infection in the first days of life put the health of the newborn at risk? Could the separation of a healthy newborn from an infected mother create further physical and psychological health problems in the dyad? The rapid and massive research effort in these three years of the pandemic has provided wide answers to these initial questions. In this review, we report epidemiological data, clinical features, complications, and management of the neonates affected by SARS-Cov-2 infection.

Clinical features of neonatal COVID-19.

The COVID-19 (SARS-Cov-2) pandemic has put a strain on healthcare systems around the world from December 2019 in China, and then rapidly spreading worldwide. The impact of the virus on the entire population and its differential effect on various age groups was unknown at the outset, specifically its severity in elders, children or those living with other comorbidities, thus defining the syndemic, rather than pandemic, character of the infection. The effort of clinicians was initially to organize differential paths to isolate cases or contacts. This impacted the maternal-neonatal care adding an additional burden to this dyad and raising several questions. Can SARS-Cov-2 infection in the first days of life put the health of the newborn at risk? Could the separation of a healthy newborn from an infected mother create further physical and psychological health problems in the dyad? The rapid and massive research effort in these three years of the pandemic has provided wide answers to these initial questions. In this review, we report epidemiological data, clinical features, complications, and management of the neonates affected by SARS-Cov-2 infection.

Impact of personal protective equipment on neonatal resuscitation procedures: a randomised, cross-over, simulation study.

BACKGROUND AND OBJECTIVE: Healthcare providers should use personal protective equipment (PPE) when performing aerosol-generating medical procedures during highly infectious respiratory pandemics. We aimed to compare the timing of neonatal resuscitation procedures in a manikin model with or without PPE for prevention of SARS-COVID-19 transmission. METHODS: A randomised controlled cross-over (AB/BA) trial of resuscitation with or without PPE in a neonatal resuscitation scenario. Forty-eight participants were divided in 12 consultant-nurse teams and 12 resident-nurse teams. The primary outcome measure was the time of positive pressure ventilation (PPV) initiation. The secondary outcome measures were duration of tracheal intubation procedure, time of initiation of chest compressions, correct use of PPE and discomfort/limitations using PPE. RESULTS: There were significant differences in timing of PPV initiation (consultant-nurse teams: mean difference (MD) 6.0 s, 95% CI 1.1 to 10.9 s; resident-nurse teams: MD 11.0 s, 95% CI 1.9 to 20.0 s), duration of tracheal intubation (consultant-nurse teams: MD 22.0 s, 95% CI 7.0 to 36.9 s; resident-nurse teams: MD 9.1 s, 95% CI 0.1 to 18.1 s) and chest compressions (consultant-nurse teams: MD 32.3 s, 95% CI 14.4 to 50.1 s; resident-nurse teams: MD 9.1 s, 95% CI 0.1 to 18.1 s). Twelve participants completed the dressing after entering the delivery room. PPE was associated with visual limitations (43/48 participants), discomfort in movements (42/48), limitations in communication (32/48) and thermal discomfort (29/48). CONCLUSIONS: In a manikin model, using PPE delayed neonatal resuscitation procedures with potential clinical impact. Healthcare workers reported limitations and discomfort when wearing PPE. TRIAL REGISTRATION NUMBER: NCT04666233.

Psychological Wellbeing of Parents with Infants Admitted to the Neonatal Intensive Care Unit during SARS-CoV-2 Pandemic.

The current SARS-CoV-2 disease (COVID-19) pandemic is a sudden major stressor superimposed on pre-existing high distress in parents of infants admitted to the neonatal intensive care unit (NICU). This study aimed to investigate the psychological wellbeing of NICU parents during the COVID-19 pandemic. Forty-four parents of 25 inpatients of the Padua University Hospital NICU were included from June 2020 to February 2021. At 7-14 days postpartum parents completed the Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), Parental Stressor Scale: NICU (PSS:NICU) and an ad-hoc questionnaire measuring parental COVID-19 related stress. About one third of parents reported extreme/high stress and a relevant negative impact on parenthood experience. Less time (82%) and less physical contact (73%) with infants due to COVID-19 preventive measures were the most frequent negative factors. Higher COVID-19 related parental stress was positively associated with anxiety, depression, NICU parental stress, stress related to NICU environment, and parental role alterations. Depression symptoms, stress related to infant condition and parental role alterations were higher in mothers. The pandemic affected parental emotional and relational wellbeing directly through additional stress due to COVID-19 concerns and indirectly through the impact of restrictions on the experience of becoming parents.

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

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

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

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

Coronavirus infection in neonates: a systematic review.

OBJECTIVE: To summarise currently reported neonatal cases of SARS-CoV-2 infection. METHODS: A search strategy was designed to retrieve all articles published from 1 December 2019 to 12 May 2020, by combining the terms 'coronavirus' OR 'covid' OR 'SARS-CoV-2') AND ('neonat*' OR 'newborn') in the following electronic databases: MEDLINE/Pubmed, Scopus, Web of Science, MedRxiv, the Cochrane Database of Systematic Review and the WHO COVID-19 database, with no language restrictions. Quality of studies was evaluated by using a specific tool for assessment of case reports and/or case series. RESULTS: Twenty-six observational studies (18 case reports and 8 case series) with 44 newborns with confirmed SARS-CoV-2 infection were included in the final analysis. Studies were mainly from China and Italy. Half of neonates had a documented contact with the infected mother and one out of three infected neonates was admitted from home. Median age at diagnosis was 5 days. One out of four neonates was asymptomatic, and the remaining showed mild symptoms typical of acute respiratory infections and/or gastrointestinal symptoms. The majority of neonates were left in spontaneous breathing (room air) and had good prognosis after a median duration of hospitalisation of 10 days. CONCLUSIONS: Most neonates with SARS-CoV-2 infection were asymptomatic or presented mild symptoms, generally were left in spontaneous breathing and had a good prognosis after median 10 days of hospitalisation. Large epidemiological and clinical cohort studies, as well as the implementation of collaborative networks, are needed to improve the understanding of the impact of SARS-CoV-2 infection in neonates.

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

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

Management of mothers and neonates in low resources setting during covid-19 pandemia.

The coronavirus disease (COVID-19) epidemic started in the Hubei province of China, but is rapidly spreading all over the world. Much of the information and literature have been centered on the adult population while a few reports pertaining to COVID-19 and neonates have been published so far. Actual guidelines are based on expert opinion and show significant differences among the official neonatal societies around the world. Recommendations for the care of neonates born to suspected or confirmed COVD-19 positive mothers in low-resource settings are very limited. This perspective aims to provide practical support for the planning of delivery, resuscitating, stabilizing, and providing postnatal care to an infant born to a mother with suspected or confirmed COVID-19 in low-resource settings where resources for managing emergency situations are limited.

Neonatal Resuscitation Where the Mother Has a Suspected or Confirmed Novel Coronavirus (SARS-CoV-2) Infection: Suggestion for a Pragmatic Action Plan.

Coronavirus disease 2019 (COVID-19), caused by the novel SARS-CoV-2 virus, is rapidly spreading across the world. As the number of infections increases, those of infected pregnant women and children will rise as well. Controversy exists whether COVID-19 can be transmitted in utero and lead to disease in the newborn. As this chance cannot be ruled out, strict instructions for the management of mothers and newborn infants are mandatory. This perspective aims to be a practical support tool for the planning of delivery and neonatal resuscitation of infants born by mothers with suspected or confirmed COVID-19 infection.

Neonatal Resuscitation and Postresuscitation Care of Infants Born to Mothers with Suspected or Confirmed SARS-CoV-2 Infection.

The first case of novel coronavirus disease of 2019 (COVID-19) caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) was reported in November2019. The rapid progression to a global pandemic of COVID-19 has had profound medical, social, and economic consequences. Pregnant women and newborns represent a vulnerable population. However, the precise impact of this novel virus on the fetus and neonate remains uncertain. Appropriate protection of health care workers and newly born infants during and after delivery by a COVID-19 mother is essential. There is some disagreement among expert organizations on an optimal approach based on resource availability, surge volume, and potential risk of transmission. The manuscript outlines the precautions and steps to be taken before, during, and after resuscitation of a newborn born to a COVID-19 mother, including three optional variations of current standards involving shared-decision making with parents for perinatal management, resuscitation of the newborn, disposition, nutrition, and postdischarge care. The availability of resources may also drive the application of these guidelines. More evidence and research are needed to assess the risk of vertical and horizontal transmission of SARS-CoV-2 and its impact on fetal and neonatal outcomes. KEY POINTS: · The risk of vertical transmission is unclear; transmission from family members/providers to neonates is possible.. · Optimal personal-protective-equipment (airborne vs. droplet/contact precautions) for providers is crucial to prevent transmission.. · Parents should be engaged in shared decision-making with options for rooming in, skin-to-skin contact, and breastfeeding..