I had the pleasure of being asked to speak to a Canadian audience of people working with newborns yesterday about the new CPS practice points for managing deliveries and newborns with suspected or proven COVID-19. Something fascinating happened over the course of the discussion and that was that we are a country divided. It didn’t help that the week prior to the CPS releasing their practice points the American Academy of Pediatrics released the following position:
“Precautions for birth attendants: Staff attending a birth when the mother has COVID-19 should use gown and gloves, with either an N95 respiratory mask and eye protection goggles or with an air-purifying respirator that provides eye protection. The protection is needed due to the likelihood of maternal virus aerosols and the potential need to perform newborn resuscitation that can generate aerosols.”
I don’t know how the Americans are going to deliver on bringing N95 masks to all deliveries and even acknowledge in their statement that this recommendation essentially holds as long as there are supplies. There are a lot of deliveries in the US and if every one requires all team members to have an N95 respirator (two nurses, RRT, MD) that will burn through supplies quickly!
The driver of this division in the country and the AAP I believe is fear butI am not in any way judging anyone for having it in these trying times. I think it is worth looking at what is being proposed for care of the newborn by the CPS and what may be motivating this fear. Who knows it may help someone work through their own feelings on this.
What has been recommended?
What the CPS recommendations boil down to is this. For attendance at a delivery in which the mother is not intubated or expected to be, providers of care for the newborn should use droplet precautions. Specifically, whether the infant is going to receive PPV, CPAP or be intubated the evidence strongly suggests the newborn is delivered uninfected so an N95 is not needed to protect health care providers. Even if the baby is born vaginally and is exposed to blood and stool, the viral load in the distal tracheobronchial tree will be low to non-existent so aerosolization would not be a concern. If the mother is going to be intubated then an N95 mask should be worn instead of a surgical mask. Outside of the delivery room in the NICU one should use an N95 mask for providing care to any newborns on CPAP or other non-invasive support as well as those who are intubated.
It is the last statement that I know has caused some confusion. Why is it that Dr. Narvey is suggesting that in the first 30 minutes of resuscitation we don’t need an N95 but then after the baby is moved to NICU we do? The issue is a pragmatic one. The earliest known case of a positive nasopharyngeal swab is 36 hours. This doesn’t mean of course that the earliest one can get horizontal transmission is 36 hours as this is when the health care providers decided to test. Presumably they were not lucky and timed it right so we have to expect at some point maybe hours or more earlier the baby became infected. As we get busier with more and more COVID suspect mothers there is a risk of people not “watching the clock” and therefore if we had said once 12 hours or 24 hours have elapsed use N95 masks for those on respiratory support we run the risk of someone losing track of time. There are a lot of babies who need PPV at birth though but not all eventually need CPAP so eliminating the need to use N95 masks when the evidence doesn’t support their use is a responsible way of preserving masks that are in short supply for those who truly need them based on true proven risk such as with adults with COVID pneumonia being intubated.
Why is there so much fear?
I blame the media to a great extent. They latch on to stories such as this one that made its way around twitter and facebook and yet there are no publications of this infant. Likely a positive infant no doubt but I suspect it was not detected minutes after birth. Then there is the case series in Jama Pediatrics that turned the world upside down a few weeks ago. I don’t know about you but my inbox was peppered with this paper from all over Canada and beyond. Looking at the paper in detail including the images is informative as what was initially touted as evidence of vertical transmission on closer inspection I think is far from it. Three out of thirty three infants tested positive on an NPA at 48 hours of age with a claim that all three had pneumonia. The authors included two x-rays for the two 40 week infants and a CT scan of the chest for the 31 week infant. Take a look at these films.
I am not a radiologist but I suspect we would have reported these films as normal. The CT scan of the chest is in a 31 week infant who had RDS and enterobacter sepsis. How would one differentiate RDS, enterobacter pneumonia or COVID19? It may be possible these three babies indeed were inoculated in the first day or two with COVID19 but I am not so sure they really had disease. If you agree with my argument here then we have multiple case series demonstrating no vertical transmission and this one case series indicating possible horizontal transmission. Why then are we hearing about care providers bring N95 masks to deliveries just in case CPAP is needed?
Fear is a great motivator
It likely comes down to the “what if” argument. What if everyone is wrong and babies can be born with COVID19? If we had an unlimited supply of N95 masks then my answer to everyone would be “if it makes you feel better then go for it and use away”. My argument for not using them at birth is twofold. Firstly, the evidence so far is that this is not a risk and secondly we don’t have an unlimited supply of N95 masks. This creates an issue for society as a whole that if we are guided by our fear we may deprive those who truly need this resource for evidence supported high risk procedures. I believe we all have a duty to provide the best care possible and working within a system with a finite amount of resources we need to really consider what happens if we let fear override what we know from evidence.
Having said all that (and this is not a cop out but reality), we are all fatigued and probably not at our best at the moment. We are fearful for our own heath and not just physicial but mental as well. I read this morning that suicide rates in the US are up 35% this year and extrapolating I would imagine that rates of depression and anxiety have gone up with it. These infants we care for deserve us to be at our very best. If fear of contracting COVID19 has reached a level for an individual that it may interfere with their ability to provide the proper steps of NRP if not wearing their “armor” in the form of an N95 mask this needs to be considered. I am not a psychiatrist nor am I pretending to be one but our mental state has a great impact on performance. I am not endorsing the use of N95 masks for everyone but I am suggesting that during this time we all take a moment and do a check in with yourself. Are you focused, are you able to think with a clear head when needed? We need to be at our best and for me I am confident that I can care for a newborn with a regular mask but I ask you since you know yourself to be truthful with yourself so we can provide the best care possible.
Please everyone stay safe!