This document provides recommendations from FOGSI, NNF, and IAP on the perinatal-neonatal management of COVID-19 infection. It addresses 20 questions on topics like care of pregnant women with COVID-19, testing guidelines, delivery location, infection control during delivery, neonatal resuscitation precautions, neonatal care protocols, testing and treatment of infected newborns, breastfeeding recommendations, visitation policies, and occupational health policies. The recommendations emphasize isolation, use of personal protective equipment, limiting exposure risk during delivery and neonatal resuscitation, rooming-in of healthy mother-newborn pairs when possible, and following national treatment guidelines that do not currently recommend specific antiviral drugs.

1. PERINATAL-NEONATAL MANAGEMENT OF COVID 19
INFECTION –GUIDELINES OF FOGSI,NNF,IAP.
DR.K.AKHILA
MENTOR: DR.G.V. HARISH PROFESSOR (DEPT.OF
PEDIATRICS, PIMS)

2. PREGNANT WOMAN WITH TRAVEL HISTORY,CLINICAL
SUSPICION OR CONFIRMED INFECTION
• 1Q)WHAT SHOULD BE THEIR CARE?
• RECOMMENDATION 1:
• They should be isolated using ICMR guidelines for non pregnant
adults.
• In absence of community spread isolation at designated
facility
• In presence of community spread isolation by home
quarantine.

3. 2.Q)WHICH PREGNANT WOMAN NEEDS TESTING FOR COVID
19?
• RECOMMENDATION 2:
• Should be done as per ICMR testing strategy.
• IN ADDITION ICMR RECOMMENDS pregnant woman residing in
clusters / large migration gatherings / containment area presenting in
labour or likely to deliver in nxt 5 days should be TESTED EVEN IF
ASYMPTOMATIC.

4. 3.Q) WHERE IN A HEALTH CARE FACILITY SHOULD A
PREGNANT WOMAN WITH SUSPECTED /ACTIVE COVID 19
BE DELIVERED?
RECOMMENDATION 3:
COVID care facilities(public/private) would be large multispeciality
hospitals with adequate space, infrastructure.
Well equipped 3 demarcated zones (wards ,OT, NICU,MICU).
If woman who delivers at non-COVID facility turns out to be positive
actions to be taken as per MOHFW’s guidelines.

5. • 4 Q)WHAT INFECTION CONTROL MEASURES SHOULD BE
UNDERTAKEN IN TRIAGE,LABOR,DELIVARY OF THESE
WOMEN?
• RECOMMENDATION 4:
• Follow standard universal precautions in addition use PPE.
Reception ,triage should be in same room which has negative
pressure.
• Minimise objects in rooms,restriction in number of attenders visiting.

6. • 5Q)WHAT SHOULD BE THE METHOD OF INDUCTION AND
MODE OF DELIVARY?
• RECOMMENDATION 5:
COVID 19 infection itself is not an indication for induction of labour
/operative delivary.
• Mode of delivary must be guided by obstetric assessment.
• Continuous foetal monitoring, monitoring oxygenation status of
woman during labour, adequate trained health care providers are
needed.

7. • 6Q)WHAT SHOULD THE SPECIFIC CARE OF THESE WOMAN?
RECOMMENDATION 6:
• Currently recommended NATIONAL MANAGEMENT includes oxygen
therapy, respiratory support,fluid therapy,antibiotics,management of
shock.
• IT DOESNOT RECOMMEND USE OF HYDROXY CHLOROQUINE OR
ANY OTHER ANTIVIRAL DRUGS.

8. NEONATAL CARE
• 7Q) WHAT PRECAUTIONS SHOULD NEONATAL RESUSCITATOR TAKE
WHEN ATTENDING DELIVARY OF A WOMAN WITH
SUSPECTED/CONFIRMED COVID INFECTION?
• RECOMMENDATION 7:
1)resuscitation to be done in a separate room or atleast 2 meters frm delivary area.
2)Minimal numbr of personnel should attend [1 FOR LOW RISK & 2 FOR HIGH
RISK]
3)Umbilical cord must be clamped properly &skin to skin contact must be avoided.
4)routine suction is not indicated
5)endotracheal medications must be avoided
6)If PPV is needed self inflating bag, mask or a T piece resuscitator to be used.

9. • 7)If intubtion is required plexiboxes with access portholes can be used
to minimize minimize aerosol spread.
• 8)NG/OG tubes,suction catheters,tapes,ET tubes placed at resuscitation area
must be discarded even if not used.
• 9)bathing is notbrecommended i/v/o hypothermia & hosp acq
infections.

10. • 8 Q)WHAT SHOULD BE THE FEEDING POLICY FOR STABLE
INFANTS BORN TO COVID 19 MOTHERS?
RECOMMENDATION 8:
“ EXCLUSIVE BREAST FEEDING IS RECOMMENDED”
• Mothers must maintain hand,respiratory hygiene (use of masks)
• If possible direct breast pumps needed to be provided.
If rooming in & exclusive breast feeding is not possible then infant must be
fed with EBM by family memb/nurse who has not been in contact with mother
/other suspected or proven case.

11. • Mother is not eligible to donate milk in:
A)covid positive donor until declared free of infection.
B)h/o staying in containment zone in prev 14 days.
C)suffering from cough,fever,sorethroat though she tested
negative.

12. • 9Q)IS IT NECESSARY TO SEPARATE BABY FROM MOTHER?
• RECOMMENDATION 9:
Healthy neonate may be roomed in with mother.
Both mother and baby must be separated from other infected /healthy
mothers and neonates.

13. • 10Q)SHOULD SYMPTOMATIC NEONATES NEEDING INTENSIVE
CARE BE NURSED IN COMMON NICU/SNCU OR ISOLATION
FACILITY?
RECOMMENDATION 10:
• YES, they must be managed in ISOLATION FACILITY.
If single rooms are not available then closed incubators or radiant warmers
placed at atleast 1 meter distance from each other must be used in a common
isolation ward for neonates.
• Isolation room must have adequate ventilation, if air conditioned ensure 12 air
changes/hour.
Separate staff must be allocated for isolation rooms.

14. • 11Q)WHAT ARE THE SPECIAL PRECAUTIONS TO BE TAKEN
WHILE PROVIDING RESP CARE TO NEONATES EXPOSED TO
COVID 19 INFECTION?
RECOMMENDATION 11:
NIPPV,HFNC preferably be avoided.
IF INTUBATION IS NEEDED:
a)Use of pre medication for non emergent intubation.
b)Use of aerosol box during intubation,suction.
C) Attach HEPA filter in the path of exhaled gas when using ventilator /ppv
device.
d)Use of PPE,intubation to be done by experienced person.

15. • 12Q)IN SYMPTOMATIC NEONATES WHAT IS THE ROLE OF
SPECIFIC TREATMENT?
RECOMMENDATION 12:
• Specific anti COVID 19 treatment _antivirals/ hydroxy chloroquine
is NOT RECOMMENDED.
Adjuvant therapy such as systemic corticosteroids,IVIG,
convalescent plasma is NOT RECOMMENDED.

16. PREVENTION AND INFECTION CONTROL
• 13Q)WHAT SHOULD BE THE SPECIFIC DISINFECTION
PRACTICES IN NICU/SNCU?
Recommendation 13:
• IF equipment/surface is visibly soiled clean with soap n water before
applying disinfectant.
0.5% sodium hypochlorite_large surfaces(floor)
70%ethyl alcohol for reusable equipment.
Hydrogen peroxide(10% w/v)for
incubators,monitors,ventilators,phototherapy units,infusion pumps…
usually with 1 hr of contact period.

17. • 14Q) WHEN SHOULD PPE BE USED?
RECOMMENDATION 14:
• RESPIRATORY PROTECTION:
Triple layered surgical mask, N 95( If aerosol generating procedures are performed)
• EYE PROTECTION:Googles/face shield.
• BODY PROTECTION:Full sleeved water resistant gown including head and complete
shoe cover.
• HAND PROTECTION :well fitting gloves.

18. • 15Q) WHAT SHOULD BE THE
BIOMEDICALWASTE DISPOSAL PROTOCOL
IN SUSPECTED/CONFIRMED COVID 19
INFECTION?
RECOMMENDATION 15:
We need to follow same biomedical waste disposal
guidelines by govt of India.

19. DIAGNOSIS
• 16Q)WHAT SHOULD BE THE TESTING PROTOCOL IN THESE
NEONATES?
RECOMMENDATION 16:
a)wHICH NEONATES? B)Which sample?
•
a)H/O exposure to COVID 19 positive
adult(mother/any other family member.
b)IRRESPECTIVE OF HISTORY any
child presenting with SARI/pneumonia
with onset >48-72 hrs of age.
NOT ON MV: NP swab >OP swab
ON MV: Tracheal swab along with NP
swab.

20. • C) METHOD OF SAMPLE COLLECTION:
NP SWAB:
• Use only synthetic fibre swabs with plastic shaft( calcium alginate swabs/
wooden shafts)
insert into nostril parallel to palate to a depth equal to distance from nostril to
ext ear opening.
• Place swab in sterile tubes containing 2 -3 ml viral transport media.
oropharyngeal swab:
swap the post pharynx( avoid touching tongue/np was/nasal secretions)
• BLOOD/URINE/STOOL SAMPLES ARE CURRENTLY NOT ADVISED.

21. • D)HOW TO STORE?
Stored & transported in icepacks at 2-8 C upto 72
hrs.
• If delay in shipping it can be stored at -70 C.
• E) where TO SEND?
• To Authorized laboratories.
• F)Which test?
• RTPCR.

22. • 17Q)WHAT SHOULD BE THE VISITATION POLICY AND PREVENTIVE
MEASURES FOR VISITORS?
• RECOMMENDATION 17:
1) Screening of visitors,suspected persons should not be allowed.
2) one healthy family member should be allowed to stay with mother and
assist her in baby activities.
3)mother may be allowed to visit if;
a)resolution of fever with out use of antipyretics in 72 hrs.
b)improvement in resp symptoms
c)negative results for 2 samples taken 24 hrs apart.

23. • 18Q)WHAT SHOULD BE THE DISCHARGE POLICY IN THESE
NEONATES?
• RECOMMENDATION 18:
• Stable neonates can be roomed in with their mothers and can be
discharged ay the time of mother discharge,
• If rooming in is not possible ,discharge can be at 24_48 hrs followed by
telephonic follow up.
• 19Q) WHAT SHOULD BE OCCUPATIONAL HEALTH POLICY
SPECIFIC TO COVID 19 PANDEMIC?
• RECOMMENDATION 19:
Such health care professional should not be put on duty and must be
replaced.
They may consider taking HCQ as prophylaxsis.

24. • 20Q)WHAT SHOULD BE THE IMMUNIZATION POLICY
IN THESE CHILDREN?
• RECOMMENDATION 20:
SHOULD FOLLOW ROUTEINE IMMUNIZATION POLICY.
This clinical practice guidelines has been jointly developed by FOGSI-IAP-NNF,advisories issued by
ICMR,MOHFW…..

25. COVID 19 AND GI
SYSTEM IN CHILDREN
DR.K.AKHILA

26. • Virus attaches to ACE 2 ,TMPRSS2 receptors of intes
cells.
• 20% of patients remained positive even after being
tested negative on resp tract.
So faeco oral route of transmission is being proposed
as another route of infection.
• New recommendation suggests that RTPCR of stool
should be performed before considering hospital
patient as negative.
• C/F: Nausea, vomitings, abd pain, diarrhea(1-8 days
of onset)

27. • KEY POINTS:
• IBD patients do not have increased risk of COVID 19,and
should continue IBD medication.
• Corticosteroids can be used to treat disease relapses.
• The use of anti TNF drugs should be continued as earlier.
• Switching from Infliximab to Adalimumab must be
discouraged unless impossible to provide i.v infusions.
• All routeine endoscopic procedures must be avoided,if in
an emergency it must be done with full PPE.

28. • COVID 19 &LIVER:
Severity elevation of lft
MILD cases 18-25%
SEVERE cases 40-60%
This may be attributed to cytokine storm…
Patients can have high CK,LDH ( ? VIRAL MYOSITIS)
Mild raised transaminases are common but serious liver dysfunction is
rare.
However raised LFT is not a contraindication of anti viral therapy
Hypoxic injury(RD),drug induced liver injury can cause abn LFT.

29. • Any new onset jaundice with raised AST/ALT must be
evaluated.
• POST LIVER TRANSPLANTATION & COVID 19:
a) Must ensure adequate preventive measures.
b)Must continue drugs(mycophenolate
mofetil,calcineurin inhibitors)
c)NO ROLE OF ANTI VIRAL DRUGS.
Hep B,Hep C, Autoimmune hepatitis patients must
continue their medications as per protocols.

30. IS GRADUAL AND CONTROLLED
APPROACH TO HERD
PROTECTION A VALID
STRATEGY TO CURB THE COVID
-19 PANDEMIC?

31. • Pandemics are the sum of epidemics in many countries.
• Though symptoms of COVID 19 are mild in children
prevalence of pneumonia with COVID 19(53%) is higher
than H1N1 influenza(11%).
GLOBALLY THERE ARE 2 BROAD APPROACHES TO TAME THE
EPIDEMIC:
a)STRICT LOCKDOWN (flatten the curve)
b)ALLOWING HERD IMMUNITY
• Combination of mitigation and controlled herd immunity
is the best accepted intervention.
• RISK MITIGATION MEASURES INCLUDE:
Cough/sneeze etiquette, freq hand washing,
physical distancing, use of masks in human presence…

32. •
BASIC REPRODUCTIVE NUMBER (Ro) DETERMINES HERD IMMUNITY
• Reproductive number (Ro):Number of sec infections produced by single primary infection.
Higher the Ro greater the herd immunity.
IN EARLIER STUDIES Ro WAS 2;BUT RECENTLY US.CDC HAS
DESCRIBED Ro AS 5.7.
EPIDEMOLOGICAL ESTIMATE SUGGESTS HERD IMMUNITY OF
70% IF Ro WAS & 80% IF Ro WAS 5.7.
• In simple terms; if 65-70% of our population is infected and acquires immunity, it becomes
less common for an infected person to come in contact with a normal person and the number
of cases will decline.
CURRENT APPROACH IN INDIA IS RISK MITIGATION PLUS
CONTACT TRACING,TESTING,QUARANTINING.

33. • As now the lockdown is removed; the spread of infection
will be at higher rate and this is the point where DUAL
STRATEGY OF SLOWING THE SPREAD
ANDPROTECTING VULNERABLE POPULATION will
help us to attain HERD IMMUNITY.
TO CONCLUDE:GRADUAL AND STAGED
ACQUISITION OF HERD IMMUNITY HELPS TO
CURB COVID 19 PANDEMIC.

34. THANK U…