|Year : 2021 | Volume
| Issue : 1 | Page : 22-27
Preterm infant with COVID-19 - A case presentation
Leena Dorairaj1, Preethi Precilla1, Mories Sankar2
1 Charge Nurse, Christian Medical College, Vellore, Tamil Nadu, India
2 Lecturer, College of Nursing, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||08-Sep-2020|
|Date of Decision||03-Dec-2020|
|Date of Acceptance||19-Jan-2021|
|Date of Web Publication||07-Jul-2021|
Mrs. Mories Sankar
CMC College of Nursing, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The coronavirus disease-2019 (COVID-19) emerged as a pandemic in December 2019. Pre-natal, post-natal and early newborn periods are considered to be highly susceptible periods in terms of the COVID-19 infection. Although there is little evidence on vertical transmission from mother to her newborn, an infection can occur after birth. This case report highlights coronavirus infection in a newborn born to COVID positive mother.
Keywords: COVID-19 infection, mothers, newborn
|How to cite this article:|
Dorairaj L, Precilla P, Sankar M. Preterm infant with COVID-19 - A case presentation. Indian J Cont Nsg Edn 2021;22:22-7
| Introduction|| |
Globally, COVID disease has emerged as a pandemic and has affected lives in various dimensions. The impact of coronavirus disease-2019 (COVID-19) on pregnancy in terms of morbidity, mortality and perinatal maternal and foetal outcomes is unpredictable. However, it is essential to propose strategies for prevention and infection control. Pre-natal and post-natal periods are considered to be high-risk period in terms of susceptibility for the (COVID-19). Although severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) is a highly transmittable virus associated with a significantly increased risk of complications among the infected population, the transmission during pregnancy from mother to the neonate remains unclear. However, transmission can happen after birth from mothers or from other caregivers. Until date, there is little evidence of the virus in amniotic fluid, umbilical cord blood, vaginal discharge, throat swabs and breast milk. Current literature suggests that paediatric population is comparatively less affected from COVID-19 than the adult population. Infants seem to be more vulnerable to SARS-CoV-2 infection with a higher severity of illness compared with other paediatric ages. Currently, the evidence for vertical transmission in pregnancy is limited, but early neonatal acquisition has been reported. In a case study reported from China, 33 women with COVID-19 infection delivered neonates by caesarean section at term of pregnancy. Out of 33 newborns, only 3 acquired COVID-19, but a post-natal transmission was postulated since amniotic fluid, cord blood and breast milk polymerase chain reaction (PCR) assays were all clear from the virus.
| Clinical Manifestations|| |
Clinical manifestations of COVID-19 infected newborns, especially preterm infants, might be non-specific and include acute respiratory distress syndrome, temperature instability, gastrointestinal and cardiovascular dysfunction. All infants with suspected COVID-19 must be isolated and monitored, whether symptomatic or not. Wang et al. identified the clinical signs or symptoms for the neonatal diagnosis of COVID-2 as thermal instability, hypoactivity, feeding difficulty, respiratory distress, chest X-ray with changes (including single or bilateral ground-glass patterns), COVID-19 diagnosis in family or caregiver of the newborn and contact with people with suspected or confirmed COVID-19. In another cohort, infants had rashes after birth; however, the rash distribution and shape differed (some maculopapules scattered all over the body and small military red papules on the forehead).,
| Transmission|| |
With the available literature, it is difficult to yet establish whether transmission can occur through mother–infant vertically or through breast milk. Studies have established that transmission mainly occurs via droplets but can also be through skin contact, faecal–oral transmission and ocular surface contact. Detection of the virus can be done by real-time PCR (RT-PCR) in bronchoalveolar-lavage fluid, sputum, saliva and in particular, in nasopharyngeal swabs which are the gold standard for diagnosis.,,,
| Diagnosis|| |
The infection status of the mother is accessed by RT-PCR for SARS-CoV-2 nucleic acid nasopharyngeal swabs and when their hospital admission was necessary, by computed tomography. After any respiratory infection, immunoglobulin (Ig) M antibodies can be detected in the blood at 3–6 days and IgG after 8 days. It is, therefore, feasible that maternal SARS-CoV-2 antibodies can be transferred through the placenta and therefore confers immunity against the virus or reduce disease severity. Previous studies show that in neonates with suspected vertical transmission, infection was confirmed by a positive RT-PCR. However, infection was suspected based on elevated anti-COVID-19 IgM and IgG levels at birth.
| Prognosis|| |
Children are identified to have less severe clinical symptoms when infected. However, the potential harm of this novel disease remains largely unknown in neonates, especially in preterm infants.
| Care of Newborn with COVID|| |
Initial identification and treatment are crucial to combat COVID-19 outbreaks. Early detection and isolation of cases will help in reducing the rapid spread of communicable diseases. The available data suggest that relatively few infants born to mothers with COVID-19 get the disease and those that are infected have good clinical outcomes.
Regarding the mother and newborn's early separation and rooming, the current evidence recommends separating newborns from mothers with confirmed or suspected COVID-19 into separate isolation rooms until the mother's transmission-based precautions are discontinued., In cases where isolation is not possible due to various reasons, care should be taken to practice social distancing, hand hygiene and infection control, and the mother should wear a facemask during contact with her newborn.
It is also important to note that breast milk has innumerable benefits for newborns, including passive transmission of antibodies against various infections. Studies have shown that antibodies to a similar virus, SARS-CoV, were detected in breast milk. To date, SARS-CoV-2 has not been detected in the breast milk of mothers with COVID-19, although it is possible that breast milk from these mothers will provide some degree of immunity. Thus, most international associations highly recommend using breast milk from mothers with confirmed or suspected COVID-19.,
Preventive measures when rooming-in is allowed
If the neonate remains in the mother's room, measures that can be taken to minimise the risk of transmission from a mother with suspected or confirmed COVID-19 to her neonate include:
- Mothers should wear a mask and practice hand hygiene during all contact with their neonates. A healthy caregiver who is not at increased risk for COVID should provide care using appropriate infection prevention precautions (e.g., wearing a mask and practicing hand hygiene)
- Engineering controls, such as maintaining a physical distance of >6 feet between the mother and neonate or placing the neonate in an incubator, should be used when feasible.
| Management of Newborn with COVID|| |
It includes airway management and respiratory support of newborns with confirmed or suspected COVID-19.
Non-invasive respiratory support
Non-invasive support includes use of nasal intermittent positive pressure ventilation, nasal continuous positive airway pressure, high-flow nasal cannula and nasal cannula oxygen therapy.
Invasive respiratory support
Rapid sequence intubation is recommended for neonates in respiratory failure with COVID-19.
Care of COVID affected healthy newborns ≥35 weeks' gestation
Routine newborn criteria, including stable physical examination findings, ability to maintain body temperature and good feeding with adequate hydration are considered to be the primary goals and are used to establish timing of discharge.
Recommendation for the mother and the baby at discharge
- It is recommended that droplets and contact precautions are followed, during contact between newborns and their mothers with COVID-19 through the use of personal protective equipment (PPE) including aprons, gloves, surgical masks and eye protection (goggles or face protector)
- Caregivers need to wash or scrub hands often, especially before and after touching the baby, breastfeeding and kangaroo mother care
- A healthy person can provide kangaroo mother care
- Routinely cleaning and disinfection of surfaces which the mother has touched should be followed
- A towel or gown over normal clothes can be used by mother to prevent the baby touching the mother's clothes
- A distance of 6 feet between the mother and baby is suggested at times when the baby does not need closer contact
- A baby needs to be brought to the hospital if he/she has symptoms of poor feeding, lethargy and respiratory distress
- Encourage breastfeeding when the mother is testing negative.
On admission, STOPS (sensorium, temperature, oxygen saturation, pulse and sugar) assessment was done (See [Table 1]).
|Table 1: On admission, sensorium, temperature, oxygen saturation, pulse and sugar were assessed|
Click here to view
| Case Report|| |
Mrs. X, a 25-year-old lady, at 33 + 5 weeks of gestational age got admitted on 26 July 2020 with the antenatal risk factor of severe pre-eclampsia and complaints of fever for 1 day on 25 July 2020.
Mrs. X. has been married for 2 years. Her last menstrual period was on 14 December 2019. She was regular in coming for antenatal check-up in a secondary hospital. She had no history of exposure to any infection or radiation and had not complained of any minor disorders of pregnancy during the first trimester. She received two doses of injection tetanus toxoid at 20 weeks–28 weeks. She developed high blood pressure and was diagnosed with gestational hypertension at 32 weeks of gestational age and was started on tablet labetalol 100 mg twice a day. On 26 July 2020 at 33 + 5 weeks of gestational age with blood pressure of 130/90 mmHg and 1 day of fever on 25 July 2020, she was referred from secondary hospital to the tertiary hospital for safe confinement and management of gestational hypertension (blood pressure 130/90 mmHg). With relevance to the history of 1 day fever on 25 July 2020, a nasal swab for RT-PCR was taken on 26 July 2020 and she was admitted in COVID-suspected ward. The swab results revealed positive for COVID- 19 and therefore she was shifted to COVID ward on 26 July 2021. She underwent an emergency lower segment caesarean section (LSCS) in view of deteriorating maternal condition.
Prior to LSCS, she received 1 dose of steroid (injection betamethasone 12 mg I/M) on 27 July 2020 at 11:40 am. On 27 July 2020, she delivered by emergency LSCS (indication was deteriorating maternal condition) a single live preterm boy baby with birth weight of 1.5 kg and Apgar score of 9 and 10 at 1 and 5 min, respectively.
Injection magnesium sulphate infusion was initiated and continued for 24 h and tablet labetalol 100 mg Twice a day was continued for blood pressure management. Blood pressure was stabilised and controlled. She was admitted for 10 days according to the Indian Council of Medical Research (ICMR) guidelines and did not have fever, cold and cough throughout the course in the hospital. She was stable and was discharged on 5 August, 2020 with strict advice for home quarantine for 14 days.
Admission of baby into neonatal unit (COVID-suspected neonatal unit)
Mrs. X's preterm boy baby born by LSCS at 33 + 5 weeks of gestational age with birth weight of 1.5 kg and Apgar score of 9 at 1 min and 10 at 5 min was admitted in COVID-suspected neonatal unit immediately after birth.
At 1st h of life, the baby had a low blood sugar of 16 mg/dl. Injection 10% dextrose 3 ml of bolus was given to treat hypoglycaemia. The baby was started on intravenous (IV) fluids for indications such as stabilising blood sugar and prematurity. The neonate was kept nil per oral for 11 h. After the initial dextrose bolus, random blood sugar value was increased to 74 mg/dl. After 11 h of life, the baby was stable and was started on 1 ml of expressed breast milk from Mrs. X.
At 20 h of life, the baby had one episode of apnoea lasting for 20 s with bradycardia and cyanosis. The oxygen saturation dropped to 60% and the heart rate was 80/min. Tactile stimulation was provided which improved saturation and heart rate spontaneously. In view of the apnoea episode and to rule out sepsis, blood for culture was obtained and the baby was started on IV injection of aminophylline (2.3 mg) every 8th h, injection crystalline penicillin 1.5 lakh (every 12 h) and injection gentamycin 6 mg (once a day) as IV antibiotic therapy. Antibiotics were continued for 48 h and stopped after 2 days since C-reactive protein was within normal limits and blood culture was sterile.
Since the mother was COVID-19 positive, at 72 h (3rd day) of life, a nasal swab was sent for the baby and the result came as positive. At 120 h (5th day) of life, the baby developed jaundice, total bilirubin value was 16.2 mg/dl and so the baby was given phototherapy for 3 days.
At 120 h (5th day) of life, the baby was able to tolerate 10 ml via nasogastric (NG) tube every 2 h. The IV fluids were tapered and discontinued. The mother was discharged on 05 August 2020. Hence, the baby was given pasteurised donor milk from human milk bank and tolerated up to 40 ml at the time of discharge.
As per the ICMR recommendations, on the 14th day of life, a second nasal swab was sent and was found to be COVID-19 negative. Hence, the baby was shifted from the COVID ward to the main neonatal unit on 12 August 2020. In the neonatal unit, the baby was nursed in an isolated unit. PPE was used by the healthcare workers while taking care of the baby. Since the mother was still on quarantine, paladai feeds with expressed breast milk was taught to the grandmother. She was confident in giving paladai feed and taking care of the baby. The baby was discharged on 18 August 2020 when the weight reached 1.8 kg. The mother was advised on early initiation of breastfeeds.
| Nursing Care Plan|| |
The nursing care of a neonate with COVID is outlined using the nursing process approach.
| 1. Nursing Diagnosis|| |
Infection related to COVID spread from the mother.
The baby will have smooth recovery and will become COVID negative.
- Isolated child in COVID suspect unit when the mother was diagnosed positive for COVID
- Shifted and managed baby in COVID-positive unit once the baby was found to be positive for COVID
- All aspects of preterm care protocols were implemented and followed
- Regular infection control precautions were taken to prevent any further infection
- The baby was closely monitored for any complications and any deviations were quickly addressed by following appropriate management protocols
- Explained to parents and caregivers about need for isolating baby and keeping baby in neonatal intensive care unit
- Reassured family about the condition of the baby and explained the positive prognosis that was possible for the baby
- Followed COVID protocol for treatment and prevention of infection. Taught COVID prevention protocol to family members
- Consistently informed the progress of the baby to parents and family.
The baby had a complete recovery and was discharged in COVID-negative state with expected weight gain after 21 days of hospitalisation.
| 2. Nursing Diagnosis|| |
Ineffective breathing pattern related to infectious process as evidenced by apnoea, shortness of breath and tachypnoea.
The baby will be able to maintain normal respiratory rate and periods of apnoea will be prevented.
- Assessed the frequency and pattern of breathing
- Observed the baby for apnoea, change in colour of skin and checked the heart rate. In one episode, the oxygen saturation dropped to 60% and the heart rate was 80/min. With tactile stimulation, the heart rate and saturation picked up immediately to 100% and 120/min
- Monitored oxygen saturation and heart rate continuously
- Checked skin and mucous membranes for pallor and cyanosis positioned the baby's head and neck in the neutral position
- Provided tactile stimulation by applying gentle rub in the soles of feet or chest wall when saturation dropped
- Administered bronchodilators-injection aminophylline (2.3 mg) every 8th h.
Apnoea was corrected and normal breathing pattern was maintained.
| 3. Nursing Diagnosis|| |
Risk for unstable blood glucose levels (hypoglycaemia) related to immature liver function and prematurity.
Hypoglycaemia will be prevented as evidenced by normal blood glucose levels.
- Assessed the general condition of the baby. Initially, GRBS measured 16 mg/dl which was treated with injection 10% dextrose 3 ml of bolus. GRBS picked up to 74 mg/dl
- Monitored for signs and symptoms of hypoglycaemia such as jitteriness, lethargy and poor feeding
- Monitored blood glucose level every 6 h
- Administered IV dextrose bolus whenever sugars dropped below 25 mg/dl
- Administered IV fluids as per order
- Provided NG tube feeds as per order on time.
Initial hypoglycaemia was effectively corrected and a further reduction in blood sugar was prevented as evidenced by normal blood glucose level.
| 4. Nursing Diagnosis|| |
Neonatal hyperbilirubinemia related to prematurity.
Baby will be able to maintain normal bilirubin level.
- Assessed the newborn's skin and eyes for yellowish discolouration
- Checked serum bilirubin level. Total Bilirubin value was 16.2 mg/dl
- Started phototherapy and continued for 3 days
- Monitored vital signs
- Maintained adequate hydration either by nasograstric or oral feeding or IV fluids
- Monitored infant's skin and eyes every 2 h during phototherapy.
Bilirubin level was reduced as evidenced by decreased yellowing of skin and eyes.
| 5. Nursing Diagnosis|| |
Imbalanced nutrition less than body requirements related to prematurity and poor sucking ability.
Optimal nutrition status will be maintained as evidenced by the normal weight gain of the newborn.
- Assessed newborn reflexes like sucking, swallowing and cough before feeding
- Assessed bowel sounds to ensure bowel function was normal
- Checked weight every day to assess progress in grwth and weight gain
- Monitored the input and output
- Provided NG feeds every 2 h
- Ensured breast milk was given by promoting the mother to express breast milk.
Optimal nutritional status was maintained as evidenced by normal weight gain. The baby's weight increased from 1.5 kg to 1.8 kg at discharge.
| 6. Nursing Diagnosis|| |
Impaired parent/infant attachment related to newborn's illness and isolation.
Parents will be able to gain confidence and will be able to take care of the baby after discharge.
- Assessed the understanding and knowledge level of the parents
- As the mother was unable to attend to the child facilitated bonding between caregiver (grandmother) and the baby
- Provided feedback on the baby's progress to the mother and father and updated her on the treatment procedures carried out for the baby
- Photographs of the baby were taken and shown
- Encouraged the parents to ask doubts and clarified their doubts using simple language
- Gave health teaching to the parents regarding newborn care at home.
Parents and grandmother verbalised their confidence in giving care to the baby.
| Conclusion|| |
Neonates are considered to be unique because of immature physiological responses. Prematurity and COVID in combination in newborns could be a management challenge for healthcare professionals. Early identification, assessment and frequent monitoring are considered to be key factors in managing newborns with COVID to enhance speedy recovery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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