COVID-19 and Neonatal Respiratory Care: Current Evidence and Practical Approach

Abstract

The novel coronavirus disease 2019 (COVID-19) pandemic has urged the development and implementation of guidelines and protocols on diagnosis, management, infection control strategies, and discharge planning. However, very little is currently known about neonatal COVID-19 and severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infections. Thus, many questions arise with regard to respiratory care after birth, necessary protection to health care workers (HCW) in the delivery room and neonatal intensive care unit (NICU), and safety of bag and mask ventilation, noninvasive respiratory support, deep suctioning, endotracheal intubation, and mechanical ventilation. Indeed, these questions have created tremendous confusion amongst neonatal HCW. In this manuscript, we comprehensively reviewed the current evidence regarding COVID-19 perinatal transmission, respiratory outcomes of neonates born to mothers with COVID-19 and infants with documented SARS-CoV-2 infection, and the evidence for using different respiratory support modalities and aerosol-generating procedures in this specific population. The results demonstrated that to date, neonatal COVID-19 infection is uncommon, generally acquired postnatally, and associated with favorable respiratory outcomes. The reason why infants display a milder spectrum of disease remains unclear. Nonetheless, the risk of severe or critical illness in young patients exists. Currently, the recommended respiratory approach for infants with suspected or confirmed infection is not evidence based but should include all routinely used types of support, with the addition of viral filters, proper personal protective equipment, and placement of infants in isolation rooms, ideally with negative pressure. As information is changing rapidly, clinicians should frequently watch out for updates on the subject. KEY POINTS: · Novel coronavirus disease 2019 (COVID-19) pandemic urged development of guidelines.. · Neonatal COVID-19 disease is uncommon.. · Respiratory outcomes in neonates seems favorable.. · Current neonatal respiratory care should continue.. · Clinicians should watch frequently for updates..

Fig. 1

Questions regarding transmission, clinical features, and optimal mode of respiratory support in neonates with suspected or confirmed COVID-19 infection. A balance between providing optimal respiratory care and minimizing exposure to healthcare workers is crucial. COVID-19, novel coronavirus disease 2019; LMA, laryngeal mask airway; NICU, neonatal intensive care unit; PPV, positive pressure ventilation. ( Image courtesy: Satyan Lakshminrusimha ).

Fig. 2

Strategies to minimize risk to neonatal health care workers. Personal protective equipment (PPE) for droplet and contact precautions (recommended for nonaerosol generating situations) and airborne precautions (for aerosol generating procedures). Airborne precautions can utilize N95 masks with eye protection or powered air-purifying respirators (PAPR) or controlled air-purifying respirators (CAPR). Tracheal intubation carries a high risk of aerosolization. The use of a viral filter, appropriately sized tracheal tube (or a micro–cuff tube) to minimize air leak, and video laryngoscopy are some strategies that can reduce risk to health care workers (HCW). ( Image courtesy: Satyan Lakshminrusimha )

Fig. 3

Differences between neonatal and adult aerosol dispersion during bag-mask ventilation. The area of dispersion is much lower in neonates due to lower airflow and smaller tidal volumes. However, a poorly fitting mask can enhance air-leak. ARDS, acute respiratory distress syndrome; COVID-19, novel coronavirus disease 2019; HCW, health care workers; LPM, liters per minute; MAS, Meconium aspiration syndrome; RDS, respiratory distress syndrome; TTN, transient tachypnea of the newborn. ( Image courtesy: Satyan Lakshminrusimha )