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In late 2019 and early 2020, outbreaks of new coronavirus (2019-nCoV) infection swept the world. The World Health Organization recently officially named the disease as Corona Virus Disease 2019 (COVID-19). On January 20, COVID-19 was included in the statutory infectious diseases of class B, and prevention and control measures were taken in accordance with the infectious diseases of class A. So far, 2019-nCoV is still raging in many foreign countries, and prevention and control will become a relatively long-term job. Newborns are susceptible people with low immunity. How can we prevent and diagnose 2019-nCoV infections in newborns?
The first diagnosis and preliminary management of neonatal 2019-nCoV infection
Neonatal 2019-nCoV infection clinical manifestations and auxiliary examination
Clinical manifestations
It is generally believed that the incubation period of the disease is 7 to 14 days. Newborns, especially premature babies, are prone to occult and non-specific symptoms, mainly manifested as vomiting, diarrhea and other gastrointestinal symptoms or only mental weakness, shortness of breath, etc. May be accompanied by systemic poisoning symptoms, such as poor mental response, feeding difficulties, etc., severe cases may be complicated by persistent pulmonary hypertension, thrombocytopenia, liver dysfunction, coagulopathy, and septic shock. The clinical classification reference "New Coronavirus Pneumonia Diagnosis and Treatment Program (Trial Version 7)" is divided into light, ordinary, heavy, and critical.
2019-nCoV-infected neonates should be differentiated from neonatal pneumonia infected with other pathogens such as Streptococcus agalactiae, Escherichia coli, Klebsiella pneumoniae, and cytomegalovirus, as well as other non-infectious lung diseases such as Identification of neonatal respiratory distress syndrome, congenital diaphragmatic hernia, pneumothorax, etc.
Laboratory examination
1. General inspection
In the early stage of onset, the total number of peripheral white blood cells was normal or decreased, the lymphocyte count decreased, and some patients had increased liver enzymes, muscle enzymes and myoglobin. In most patients, C-reactive protein and erythrocyte sedimentation rate are elevated, and procalcitonin is normal. In severe cases, D-dimer increased, and the number of peripheral blood lymphocytes decreased progressively. Because of the few cases of neonatal infections, the characteristics of laboratory tests are not yet clear.
2. Pathology and serology
Etiological examination: RT-PCR or/and NGS method can be used to detect new coronavirus nucleic acid in nasopharyngeal swabs, sputum and other lower respiratory tract secretions, blood, feces and other specimens.
Serological examination: Most of the new coronavirus-specific IgM antibodies begin to appear positive 3 to 5 days after the onset, and the recovery period of IgG antibody titer is 4 times or more higher than that of the acute stage.
Serological examination has the characteristics of fast and convenient. The immunodetection method can detect serum virus IgM and IgG antibodies within 15 minutes. The overall test sensitivity is 88.66%, the specificity is 90.63%, and fingertip blood, serum and venous blood plasma There is a high test consistency between the samples in the test. Serological tests are applied to a large sample population, and the positive rate of the test is significantly improved, complementing the advantages of the pathogenic test.
Film degree exam
In the early stage, there were multiple small patch shadows and interstitial changes, with obvious extrapulmonary zone. Then it develops multiple ground glass shadows and infiltration shadows of the lungs. In severe cases, lung consolidation may occur, and pleural effusions are rare. Suspected cases with respiratory symptoms should be examined on the upper chest X-ray as soon as possible. Consider the impact of CT radiation on newborns. In the diagnosis and follow-up of neonatal cases, the epidemiological history and clinical manifestations should be fully combined. First, consider other imaging examination methods, such as chest radiographs or lung ultrasound.
Newborn 2019-nCoV infection diagnosis
Suspected infection
Newborns delivered by mothers with a history of 2019-nCoV infection within 14 days before delivery and within 28 days after delivery; during the newborn period, other contacts with a history of 2019-nCoV infection (including family members, caregivers, medical staff, visits Person), regardless of the presence or absence of symptoms, suspected cases of infection should be considered.
Confirmed cases of infection
The suspected case is diagnosed with one of the following etiological evidences: real-time fluorescent RT-PCR of respiratory tract specimens or blood specimens to detect 2019-nCoV nucleic acid positive; viral gene sequencing of respiratory specimens or blood specimens, highly homologous to known 2019-nCoV; new serum Coronavirus-specific IgM antibodies and IgG antibodies were positive; serum new coronavirus-specific IgG antibodies changed from negative to positive or the recovery period was 4 times or more higher than the acute period.
2019-nCoV-infected neonates first diagnosis and initial management
Newborn management in delivery rooms and operating rooms
Suspected and confirmed pregnant women should give birth in designated hospitals with effective isolation and protective conditions. The neonatal doctor should arrive at the delivery room or operating room 30 minutes before delivery, so that they have enough time to understand the condition of the pregnant woman, strictly implement comprehensive protective measures and prepare equipment and equipment.
1. Newborns suspected of 2019-nCoV infection mother delivery
A neonatal doctor conducts a preliminary examination immediately after delivery of the suspected mother’s newborn, and the newborn is transferred to the neonatal isolation ward after the necessary neonatal resuscitation. If the mother has tested negative for 2019-nCoV nucleic acid for 2 consecutive times (at least 1 day apart), the isolation will be lifted. ; If the mother's 2019-nCoV nucleic acid test is positive, isolation observation/diagnosis and treatment for more than 14 days, the isolation can be lifted if the condition is generally good.
2. Diagnosis of newborns delivered by 2019-nCoV infected mothers
If the child has severe clinical manifestations, he should be promptly transferred to the prevention and control designated hospital for further diagnosis and treatment; after the confirmed mother’s newborn is delivered, the neonatal doctor will conduct a preliminary examination and transfer the necessary neonatal resuscitation to the neonatal isolation observation ward. Newly diagnosed neonates are transferred to designated hospitals for separate isolation treatment as soon as possible under the premise of ensuring the safety of transport.
3. Focus on points
Coronavirus may cause serious adverse perinatal outcomes. Suspected/confirmed mothers will be screened for 2019-nCoV infection. Newborns will be routinely collected for throat swabs, airway secretions, blood and stool samples for 2019-nCoV nucleic acid testing; It is not necessary to squeeze the umbilical cord or delay the ligation of the umbilical cord after delivery. The umbilical cord should be clamped and cut as soon as possible to reduce the risk of vertical transmission of mother and child; direct breastfeeding during isolation observation or treatment is not recommended until the 2019-nCoV infection is eliminated or cured Feasible breastfeeding.
Neonatal management in home isolation and hot clinic
1. Promote the establishment of modern information channels, such as telephone, social media, APP, video, etc., and communicate with parents on newborn care, feeding, and control in a timely manner, so that parents can solve problems online under the guidance of doctors and reduce exposure opportunities for newborns . Ma XL and other developers have developed an online follow-up app to follow up on neonatal jaundice, and achieved good results.
2. Pre-examination and triage
All neonatal patients in outpatient clinics need to be separated by the hospital, and children with no epidemiological history should be shunted. According to the triage with or without fever, they are directed to the home isolation outpatient area or the non-favored clinic area, and the number of accompanying parents is limited; pre-check points The medical staff routinely asks the parents of the children who have visited the clinic to inquire about the epidemiological history, fever and respiratory infection symptoms. The people involved include family members, caregivers and visitors, and sign relevant commitment documents.
3. Management of neonates suspected of 2019-nCoV infection
The doctor at the first consultation initially considered a suspected child and immediately performed a single room isolation treatment (isolation room or isolation observation area for fever clinic), and asked a specialist in the hospital for consultation. The results of the consultation are immediately reported to the director of the department, the medical department and the hospital's sensory department. The suspected cases are reported directly to the network within 2 hours (requirements for the management of infectious diseases of the class A). After the consultation, the children with suspected infection are considered. Sexual antibody detection; the suspected child is not considered after the consultation, and the child is treated in accordance with the routine treatment of the neonatal outpatient emergency department.
2019-nCoV infection prevention and control of newborns
The 2019-nCoV infection has the epidemiological characteristics of rapid transmission. The R0 evaluation value is 2.2. Early diagnosis, early isolation, and personal protective measures must be taken to reduce the risk of transmission. Clinical prevention and control should control three major links: controlling the source of infection, blocking the transmission route, and protecting susceptible people, in order to effectively prevent the spread of 2019-nCoV in newborns.
Infection source management
Suspected or confirmed patients within 14 days before delivery and within 28 days after delivery, and contacts (including family members, caregivers, medical staff, and visitors) who are directly exposed to the history of 2019-nCoV infection, need to maintain isolation from the newborn and choose a body Healthy family members take care of the children, closely observe the children's health status, and measure body temperature once a day in the morning and evening, and record it. If symptoms such as fever or reaction, poor milk intake, and shortness of breath, you should immediately go to the designated hospital for prevention and control.
Management of infection routes.
Airborne droplets and close contact transmission are the main routes of transmission; there is a possibility of transmission through aerosols in a relatively closed environment when exposed to high concentrations of aerosols for a long time; ACE2 is a receptor for 2019-nCoV, and ACE2 is in the ileum It is commonly expressed in a variety of cells such as colonic absorbable intestinal epithelial cells, and the samples of toilets and sinks in the diagnosed patients are tested positive. Viral shedding in feces is a potential route of transmission. Strictly limit outing activities, do not kiss children, do not breathe or breathe for newborns, close contact with newborns should actively wear masks to stop the spread of droplets; wash hands frequently, maintain sanitation and disinfection, children’s bottles, toys and daily necessities need to be regular For disinfection, objects that are in frequent contact should be wiped with 250-500 mg/L of chlorine-containing disinfection solution to block the spread of contact; maintain indoor ventilation, regularly turn on air purifiers, ultraviolet disinfection, etc. to block the spread of aerosols; The secretions and excreta should be marked and strictly treated as infectious medical waste, otherwise it will easily become an important source of neglected infection.
Management of vulnerable groups.
First of all, during the epidemic period, it is necessary to adjust the neonatal follow-up clinic, neonatal specialist clinic and vaccination clinic, and conduct online consultation and guidance through WeChat, telephone, video, etc. instead of face-to-face neonatal visits and child health examinations; second, vaccination The vaccine can avoid neonatal infections. Currently, the 2019-nCoV vaccine has been developed. If the vaccine proves to be safe and effective in animal models, a large-scale clinical trial can be conducted as early as June. Other vaccines with no strict time limit can be postponed to reduce the exposure of the population.
2019-nCoV infection medical staff prevention and control
In the prevention and control of epidemics, medical personnel are the makers and implementers of medical treatment measures, and infection prevention and control are particularly important. Ensuring adequate staff on duty, ensuring that medical staff take regular breaks, maintaining a happy mood, giving psychological counseling when necessary, reasonable diet, and strengthening immunity are important preventive measures for medical staff.
Management of consultation medical staff in delivery room or operating room
Prenatal diagnosis 2019-nCoV infection delivery room (operating room) delivery of newborns, medical staff implement second-level protection measures: wear N95 masks, hats, goggles, rubber gloves, wear work clothes, isolation clothes, protective clothes, and even wear if necessary Body protective clothing; prenatal diagnosis of 2019-nCoV infection delivery room (operating room) delivery of newborns, medical staff implement three levels of protection measures: on the basis of second-level protection, wear one-piece protective clothing, face mask, helmet.
Management of fever clinics for newborns
Medical staff attending the clinic shall implement second-level protection measures, and specimen collection personnel shall implement third-level protection measures.
Management of neonatal isolation wards
After entering the neonatal isolation ward, medical staff should strictly wash their hands, wear isolation clothes, gloves and surgical masks. After entering the isolation room, they need three levels of protection. Medical staff will integrate the diagnosis and treatment operations to minimize contact with the patient. The vascular access is closed management , Adopt safe indwelling needle and needle-free infusion connector to prevent needle stick injury.
In summary, the clinical manifestations of 2019-nCoV infection in neonates are not typical, and the imaging features are not obvious. Therefore, we should pay close attention to the clinical manifestations of 2019-nCoV infected neonates, strengthen prevention and control measures, effectively control the epidemic, and protect newborns It is of great significance to safely pass the epidemic period.
Author: Fudan University Zhongshan Hospital, Qingpu Branch
Pediatrics Jia Xiyan Deputy Chief Physician
Audit: Qingpu Branch of Zhongshan Hospital Affiliated to Fudan University
PediatricsXu LingminChief physician