Managing infants born to mothers with COVID-19: Guidance by AAP and AHA

The American Heart Association (AHA) and American Academy of Pediatrics have released their recommendations for providing emergency cardiovascular care, including CPR, to pediatrics patients with known or suspected COVID-19.

They have issued guidance on managing infants born to mothers with COVID-19. Newborns of women with positive or pending COVID-19 test results should be considered persons under investigation, and clinicians should use gowns, gloves, and standard mask and eye protection during clinical encounters. Newborns should be bathed as soon as possible to remove any virus potentially on the skin, and temporary separation from the mother should be considered.

Key recommendations are-

When caring for pediatric patients with known or suspected COVID-19:

1. Use Standard and Transmission-Based Precautions during the care of patients with suspected or confirmed COVID-19 (Source: CDC, accessed 3/23/2020)

a. Aerosol-generating procedures (e.g., CPR, endotracheal intubation, non-invasive ventilation) expose providers to a greater risk of disease transmission. These procedures should be performed in Airborne Infection Isolation Rooms (AIIRs) and personnel should use respiratory protection. Limit the number of providers present during the procedure to

only those essential for patient care and procedural support. The room should be cleaned and disinfected following the procedure. (Source: CDC, accessed 3/23/2020)

b. Patients with known or suspected COVID-19 should be cared for in a single-person room with the door closed. AIIRs should be reserved for patients undergoing aerosol-generating procedures. (Source: CDC, accessed 3/23/2020)

c. Hand hygiene

d. Personal Protective Equipment (PPE)

• Respiratory protection: Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure.

When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19.

(Source: CDC, accessed 3/23/2020)

• Eye protection

• Gloves

• Gowns: If there are shortages of gowns, they should be prioritized for aerosol-generating procedures, care activities where splashes and sprays are anticipated, and high-contact patient care activities that provide opportunities for transfer of pathogens to the hands and clothing of providers.

2. Additional considerations for aerosol-generating procedures

a. If intubation is needed, use rapid sequence intubation with appropriate PPE.

b. If possible, avoid procedures which generate aerosols (e.g., bag-valve mask, nebulizers,non-invasive positive pressure ventilation).

c. Due to the risk of disease transmission with non-invasive ventilation, consider proceeding directly to endotracheal intubation in patients with acute respiratory failure, weighing the potential for ventilator shortages.

The American Heart Association understands the difficulty in caring for pediatric patients during this challenging time, especially when resuscitation is needed," said Comilla Sasson, MD, PhD, FAHA, FACEP, a practicing emergency room physician and vice-president for emergency cardiovascular care science and innovation at the American Heart Association. "Together with the American Academy of Pediatrics, we are doing everything we can to make it easier by offering guidance to minimize the spread of COVID-19."

"As the COVID-19 pandemic continues to impact more communities in the U.S., it's important for all caregivers and first responders to understand how to provide critical care to infants, children and adolescents in the safest way possible," said Susan Fuchs, MD, FAAP, a practicing pediatric emergency physician and co-editor of the Pediatric Education for Prehospital Providers (PEPP) 4th Edition textbook.

The information is drawn primarily from the U.S. Centers for Disease Control and Prevention and World Health Organization recommendations. Specific guidance around caring for pediatric patients with known or suspected COVID-19 is provided for aerosol-generating procedures (e.g., CPR, endotracheal intubation, non-invasive ventilation), personal protective equipment, and airway management and use of noninvasive ventilation. Additional guidance is offered for emergency medical dispatchers, pre-arrival notification, EMS clinician practices modifications including personal protective equipment, aerosol-generating procedures and risk of disease transmission, and transport considerations.

The information was published on March 27, 2020 on the American Heart Association's CPR website, www.cpr.heart.org.