Ex micro-premie with BPD and now Covid

[HickOnACrick]

Former 27 weeker, 895 gram male (now 1700+ and 36 and 6/7). STAT C-section for abruption, Apgars 1/3/5. Suspected antepartum anoxia/hypoxemia based on blood gases. Developed renal failure, elevated transaminases, etc. Very difficult respiratory mgmt, at 2 months of life, still on 5LPM HFNC and 50% FiO2 which is far outside the norm for us. 

 

This weekend, increased frequency and severity of apnea prompted a septic workup, including viral respiratory panel by RT-PCR. Negative for all the common resp viruses (including RSV, metapneumo, and flu), negative blood culture (now day 3), but positive for SARS-CoV-2. Tested mother, negative at admission, positive now. We are conducting surveillance on all staff, but right now it looks like he got it from mom. Mom now admits to some nausea and pharyngitis last week when the baby started becoming acutely ill. Mother is a healthcare worker and has not been vaccinated. 

 

Baby has moved from HFNC to NIPPV +6 and a backup rate of 35. He is dependent on the backup rate. His fiO2 need has decreased to about 30%. We started dexamethasone 2 days ago. He also had/has mild PHN as evidenced on echo last week and clinical lability. His only meds include caffeine, midazolam prn, dexamethasone, and multivitamin with Fe. We kept him NPO for about 24 hrs when he was most acutely ill, but as of this morning, he is back on full feeds. He received 48 hrs of nafcillin and gent this weekend. 

 

By my research, this is the first case of a former ELBW baby acquiring and becoming symptomatic with SARS-CoV-2 in the NICU. 

 

Has anyone experienced, or know of similar cases? If so, any special considerations for management? Is there the possibility of delayed severe symptomatology as is reported in the adult population? 

[Medhaw]

Good lesson for all. No experience so far. May be long mothers with babies in NICU long term should be checked every two weeks or so.

[Stefan Johansson]

@HickOnACrick thanks for sharing - have you considered to publish this experience?

In Sweden (Uppsala, neighbouring city to Stockholm), there was an ex-preterm infant that came back to the ER a few weeks after discharge and ended up on the vent. Being Covid+. I don't know anything from first-hand sources, but read about this spring in the national newspaper https://www.dn.se/nyheter/sverige/sa-raddades-bebisen-i-uppsala-sveriges-yngsta-covid-patient/, maybe a Google translate would make the long article there possible to read in Google-English 

 

[HickOnACrick]

I have found a few case reports about NICU graduates with BPD being admitted to PICUs with Covid-19. However, I have yet to find a case report of a former ELBW infant, who is still in the NICU, acquiring SARS-CoV-2, and deteriorating as a consequence. 

 

With regards to publishing, well, that is in part why I started this thread. It seemed like I was observing a novel effect of a novel virus, but wanted to see if others were seeing it as well. I reached out to my local University NICU's Medical Director, and they have not seen it in their NICUs. I have a couple other calls in to other large centers, but am awaiting their response(s). I plan to get IgG and IgM ELISA next week, considering whether it's worth testing mom's milk for virus and/or antibody. My local support for academic endeavors is greatly limited (county hospital), so I would welcome a collaboration if one has access to a more robust academic infrastructure. 

 

The baby's FiO2 needs are slightly higher today (35-40%). Work of breathing is better today, but baby remains dependent on the backup rate on NIPPV (currently set at 35 bpm). I have tested this daily by decreasing the rate at bedside. Baby continues to ride the rate and quickly desaturates if rate is weaned. A rate of 25 led to SpO2 of 70%.

 

This, along with some increased irritability have me slightly concerned about neurologic sequelae. Thus far, his cranial ultrasounds have been clear - even for PVL. Baby is not receiving any sedation that would interfere with respiratory drive. The last blood gas was typical of a BPD baby - a mostly compensated respiratory acidosis - thus I believe the CO2 is available to drive respirations. We have discussed whether to do an LP every day for the past 5 days, but we do not feel the baby is clinically stable enough for that yet. 

 

Echo yesterday was unchanged from about 2 weeks ago - PFO with mild PHN. Function looks good. 

 

We are not routinely obtaining blood gases or radiographs. Prior to NIPPV, while on 5 LPM HFNC, baby had significant atelectasis, low volumes, and chronic changes. We plan for a repeat chest radiograph tomorrow to track changes, if any. 

 

Most recent CBC has trended toward neutropenia, but the ANC was still ~2500. 

 

We started more frequent and prolonged tummy-time today. I guess the kids call that "proning" these days  We have considered chest physiotherapy, but worry the baby will not tolerate cup percussions. 

 

Baby remains on full feeds and oral dexamethasone, caffeine, MVI, and midazolam as needed. We lost IV access, and although it makes us nervous to not have access, we do not have a need for an IV right now. Caffeine dose is 5 mg/kg BID. 

 

At this time, we are using the DART protocol for dexamethasone. We made this decision based on our comfort level with using this regimen. However, if the FiO2 need continues to increase, we may need to rethink the dose. By limited accounts, it seems in PICUs they are using a dose about 4x the starting DART dose. 

 

It seems about once per year, we have cared for a former ELBW baby, that has never left the NICU, and acquires a viral respiratory pathogen and has clinical viremia. We are day 4 of severe symptomatology with this baby. We understand that some adult covid patients have a "honeymoon" period, lasting for 7-10 days, then can acutely become critically ill. By our experience with other VRPs, this is about the time we expect slow but continued improvement. 

 

Overall, we are trying to balance the baby's ex-premie with BPD needs with the additional support for his suspected Covid. Thus we have continued to limit blood draws, maximize nutrition, minimize radiation, continue the MVI, etc. 

 

 

[DocForBabies]

I think it's concerning that this baby who had such bad lung disease to begin with , now has super-imposed covid-19 infection. I haven't encountered a new NICU covid-19 infection (yet), but wondering if micro-aspiration is something to consider in this baby. I did have a ELBW patient with late pulmonary hypertension who responded to management of reflux and was weaned off O2.

[HickOnACrick]

Going off service for a week, so an update. 

 

Baby has continued to slowly improve. Baby is now on HFNC 4LPM with oxygen needs around 30%, remains on full enteral feeds, fortified, and is gaining weight again. 

 

We may need to prolong the steroid course. As the course has weaned, baby's FiO2 needs have increased slightly (we have had the baby as low as 25% FiO2). 

 

The most recent chest radiograph shows improved expansion and aeration. Fibrosis and chronic changes are not the worst we have seen. We would not define the most recent CXR as being consistent with cystic BPD. 

 

We have spoken to a number of larger NICUs. This scenario (caretakers spreading C19 to NICU babies) is being seen in areas of the country where the incidence of C19(+) in the general population is the greatest. 

 

We have counseled our other families, especially those with the most fragile babies, that their social/work life needs to be a bubble of sorts. 

[Hamed]

Thanks a lot @HickOnACrick for sharing this case and updating us on it. I am looking forward to hear further updates whenever you can.

I have a concern about initial placing a resp. distress case on HFNC less than 8LPM. Is 5 LPM the standard starting flow used in your NICU?

The pressure given by the HFNC is variable, but in our NICU we usually consider it is about 1 to 1.5 cmH2O less than a nCPAP with the same PEEP figure, and thus using a HFNC of 5 L would possibly give a PEEP of 3.5~4 cmH2O.

Would you please let us know how were babies nearby this case or infants cared by the same nurses caring for this one managed? 

 

[HickOnACrick]

As of yesterday, baby has continued to wean slowly on HFNC. FiO2 needs are mostly <40% on 3 LPM. Most importantly, baby has started bottle-feeding. We were very concerned about oral aversion. 

 

Baby remains on caffeine, multivitamin with iron, and Pulmicort NEB BID. Baby is gaining weight on a mixture of EBM and Neosure. 

 

When we have a baby that seems to be failing on HFNC, we generally move them over to NBCPAP or NIPPV, but we have used increased LPM flows (>5 LPM) on occasion. I have colleagues in other NICUs that prefer using HFNC at 6-8 LPM vs NBCPAP. 

 

We conducted surveillance PCRs on all staff that had a significant exposure to the family. We assigned the baby as a one-to-one nurse assignment so that nurse only cared for one baby. Baby has since come out of isolation. No other babies became symptomatic during this time, so no other babies have been tested for VRPs.