Diagnosis and treatment experience of COVID-19 in a three-monthold baby

Qing-Xia Wu, Hong-Ai Li, Yue-Hua Zhang, Yi-Ping Sun, Xiao-Mei Hu, Yan-Xuan Li, Chao Deng, Wei Xiang

1.Department of Infectious Disease, Haikou People’s Hospital, Central South University Xiangya School of Medicine Affiliated Haikou Hospital, Haikou 570208, China

2.Department of infant Health Care, Hainan Maternal and children’s Medical Center, children’s Hospital of Fudan University at Hainan, children's Hospital of Hainan Medical University, Haikou 570311,China

3.Intensive Care Unit, Haikou People’s Hospital, Central South University Xiangya School of Medicine Affiliated Haikou Hospital, Haikou 570208, China

4.Key Laboratory of Tropical Translation Medicine of Ministry of Education, Hainan Medical University, Haikou 571199,China

Keywords:

ABSTRACT

1. Background

The corona virus disease 2019 (COVID-19, novel coronavirus pneumonia, NCP) is an acute respiratory infectious disease that is classified as Class B but managed as Class A infectious disease by the Law of People's Republic of China on the Prevention and Control of Infectious Diseases since January 2020. The treatment plan of NCP was updated to the seventh edition [1]. The editorial board of Chinese medical science and Chinese Journal of Pediatrics issued the recommendation of the diagnosis and control of COVID-19 pneumonia of children (trial version 1) [2]. Through a series of prevention and control and medical treatment measures, the rising trend of China's epidemic has been curbed. Because covid-19 has the characteristics of strong infectivity and rapid progress of disease, active and effective prevention and control and nursing measures are extremely important for infected patients, especially for infants and young children. The infant's respiratory system and organs development is imperfect. Severe coughing can easily lead to the increase of abdominal pressure. Food backflow into the trachea, further aggravating coughing. In addition, the infant respiratory center is poorly regulated, and hypoxemia and carbon dioxide retention are prone to occur during cough. Therefore, reasonable nursing is very important for the patients with covid-19. Now the nursing experience of the first confirmed case in Hainan Province is summarized as follows.

2. Clinical Data

2.1. General information

The infant, female, was hospitalized on January 26, 2020 due to fever for 4 hours. The infant was G1P1 and was vaginal delivered with full term, she was breast-feeding and healthy previously, immunizations up to date, and had no underlying disease . The infant had fever at 7:00 a.m. on January 26, the temperature of 38.2 ℃, no nasal obstruction, no cough, no spitting, no shortness of breath or cyanosis, no nausea, no vomiting or diarrhea. She continued to have a good appetite, good mental response, and loud crying.. Four hours later, the ambulance was transferred to our hospital for treatment. Her temperature at admission was 38℃, heart rate 130 beats/min, respiratory rate 30 breaths/min, and body weight 7 kg. Mental reaction was OK, skin and mucosa of the whole body were complete, no rash, conjunctiva was not congested, lip was red, no cyanosis, pharynx was congested, breathing was stable, breathing motion of both lungs was symmetrical, breathing sound of both lungs was clear, dry and wet rales were not obvious, heart sound was powerful, rhythm was neat, murmur was not reached, abdomen was flat and soft, subcostal 1 cm of liver, the spleen was not reached, the muscle strength and tension of limbs were normal, and the nervous system was normal. Laboratory tests of peripheral blood showed white blood cells were 9.68×109/L, 44.3% lymphocytes, 44.6% neutrophil, hemoglobin level was 113 g/L, platelets were 494×109/L, C-reactive protein was 5.66mg/L. Urine routine test was normal. Feces routine test showed lipid drop +. The results of rapid detection of influenza A and B antigens in throat swabs were negative. There were no abnormal changes in blood, liver and kidney function, electrolytes, myocardial enzymes and antistreptolysin O titer (ASO). The novel coronavirus nucleic acid was collected from the ward of the negative pressure ward and breastfed after admission. The novel coronavirus nucleic acid was collected on the same day (January 26th) as the critical value. Paramivir was used for anti viral treatment, and azithromycin and ceftazidime were used to treat infection and symptomatic treatment. In January 27th, novel coronavirus nucleic acid was positive and diagnosed as COVID-19. On January 29, the infant developed cough and foaming at the mouth, and the symptoms were relieved by treatments of ambroxol, atomization, vibration and expectoration. The novel coronavirus nucleic acid in throat swab was retested in January 30th. Repeated pharyngeal swabs on February 3rd, 5th, and 9th were negative for SARS-CoV-2. Additional sampling from February 5th detected SARS-CoV-2 nucleic acid in feces, and sputum but not urine. On February 9th, her fecal specimen test of SARS-CoV-2 nucleic acid remained positive, but throat swab test turned negative. On February 11, the infant was cured and discharged from the hospital.

2.2. Basic principles of nursing

Firstly, infection prevention and management:the medical staff shall strictly implement the hand hygiene standards of the medical staff. The staff in the isolation area and isolation ward shall adopt the secondary and tertiary protection according to the needs. The intravenous injection shall use the retention needle or safety type retention needle to avoid needle stabbing. There was no infection among the medical staff.

Secondly, protection of infant and her families: for inpatients, according to the protection requirements, suspected cases or confirmed cases should be placed in different areas, and visits and accompanying care are not allowed. However, the infant was a 3-month-old female who needs to be breastfed. According to the actual situation of the infant, the negative pressure ward is adopted for isolation in the company of her parents. According to the protection requirements, patients wear medical surgical masks during hospitalization, but babies under 1 year old are not suitable to wear masks. Wearing masks for babies is easy to cause breathing difficulties and suffocation, which is not conducive to observe the situation of children. This kind of children are mainly passive protection. The carer should wear a mask, do not sneeze, exhale or cough at the infant. We guided her parents to wear masks and trained them of seven step washing techniques to strengthen their awareness of hand hygiene. The novel coronavirus nucleic acid was negative in January 26th when the infant was admitted to hospital for swallowing specimens. The infant’s father developed fever 37.4 degrees in February 2nd, accompanied by fatigue, no cough, rhinorrhea, shortness of breath and other respiratory symptoms. Interferon α2b was sprayed on his mouth and bilateral nasal cavities but there was still low-grade fever. His whole blood cell count was normal. Chest CT was concerning for infection in the lingula of his left upper lung lobe with micronodules. On February 2nd, his throat swab specimen tested positive for SARS-CoV-2 nucleic acid. Hence, the COVID-19 was diagnosed and he was transferred to the isolation ward of adult infectious disease ward. On February 3rd and 4th, the infant’s mother had two consecutive throat swab specimens, and tests were positive for SARS-CoV-2 nucleic acid which was also confirmed by the Hainan provincial reference laboratory on February 5th.Chest CT imaging showed bilateral upper lung exudative lesions; however, the mother did not demonstrate any clinical symptoms. Based on above evidence, the mother was identified as an asymptomatic carrier.

Thirdly, secretions of patient management:strict chargement of patients' respiratory secretions, excreta, vomit, etc. After a large number of pollutants were completely covered with disinfectant powder, bleach powder or one-time absorbent materials containing water absorption components, a sufficient amount of 5 000-10 000 mg / L chlorine containing disinfectant solution was poured, and the effect was more than 30 minutes, and then it was cleaned up. Avoid contacting with contaminants during removal. The excreta, secretions and vomitus of the patients were collected in special containers. The disinfectant containing 20 000 mg / L chlorine was used to soak and sterilized for 2 hours according to the proportion of feces and drugs.

2.3. The main points of nursing

Firstly, dilute the sputum and keep the respiratory tract unobstructed: due to the small size of the infant, the lungs were underdeveloped, and the ability to spontaneously cough was weak, it was not possible to spontaneously sputum. Keeping the airway smooth, atomizing and shaking the back to expel sputum is one of the key points of care. The key to our care was to reduce phlegm and expel phlegm and keep the airway smooth. Give the infant Q8H nebulized inhalation. The nebulized inhalation turned the liquid into a fine aerosol. As the infant inhales into the respiratory tract, it could humidify the respiratory tract, dilute the sputum, and reduce the viscosity to facilitate sputum discharge. Vibrating back-pasting care was given every two hours; parents were instructed to pat the back of the infant with hollow palms from bottom to top, from both sides to the center, and tap the infant's back rhythmically with wrist force for 5 to 10 minutes. The accumulated sputum could flow to the trachea and pharynx, and the sputum could be sucked out by sucking the sputum, and good results were obtained.

Secondly, reasonable feeding, guiding the transfer of milk: Nutritional support and management are very important for the rehabilitation of the disease. For patients with NCP, strengthen nutritional support and give a high-calorie, high-protein, highvitamin, easy-to-digest diet.The patient continued breastfeeding after admission, but because the mother of the infant was identified as an asymptomatic carrier and must be isolated for observation, so breastfeeding was stopped. Breastfeeding to artificial feeding requires a process, so there were feeding difficulties during the breastfeeding period. The infant's performance included nonsense, not sucking the bottle, easy to choke, easy to hypoglycemia, we should give the bottle feeding, when the infant refuses, a small amount of syringe can be given into the drop, but pay attention to stop the infant's comfort when the infant cries, Avoid choking milk causing pneumonia to enter the trachea and lungs. The first feeding was successfully given 30 ml via bottle sucking, the second feeding was 90 ml successfully after 1 h, and the third feeding was performed 3 h later. The infant accepted the bottle feeding method and successfully transferred to milk. When feeding the bottle, the size of the milk hole should be appropriate. Choose a 3-monthold nipple. If the milk hole is too large, the infant will swallow the trachea or reflux from the nasal cavity by mistake; if the milk hole is too small, sucking will be difficult. There are some points of notes to guide parents of manual feeding: ① clean the bottle in time and sterilize it in the bottle sterilizer steam; ② do hand hygiene before and after each feeding; ③ adjust according to the energy of the milk powder; ④ sucking after crying because of hungry children Larger, it is easy to cause a lot of air to enter the stomach when eating. After or during feeding, pat the back of the infant gently until the gas burps. At the beginning, a small amount of feeding can be given, and the children can be fed according to the required amount and on time after the milk was successfully transferred. The infant was hospitalized for half a month, and the growth and development were normal, and the body weight increases by 0.5 kg.

Thirdly, vital sign monitoring and nursing: strictly monitor the changes of patients' vital signs. Focus on monitoring body temperature, respiratory rhythm, frequency and depth, and blood oxygen saturation. Fever patients are given antipyretic treatment according to doctor's orders. After using antipyretic drugs, body temperature changes and sweating should be closely monitored. The observation of the disease of children with NCP mainly includes: ① observation of children's mental state and vital signs; ② blood oxygen saturation monitoring, timely detection of blood oxygen changes, such as oxygen saturation≤93%, report to the doctor and give oxygen, Cooperate with the doctor for treatment; ③ Whether there are sputum sounds in the lungs, whether there is upper respiratory tract obstruction, if there is no shortness of breath, cyanosis, etc., if breathing is laborious and there is phlegm in the throat, immediately remove respiratory secretions; ④ record Daily feeding status and regular weight measurement to evaluate the nutrition and feeding status of the infant.

Fourthly, psychological assessment and support: For adult patients, isolation is prone to problems such as fear, anxiety, anger, loneliness, and sleep disturbances, and the type and needs of the patients' mental states are correctly assessed. Evaluate the patient's cognitive changes, emotional responses and behavior changes, and give patients psychological adjustment and other interventions. Provide appropriate emotional support to encourage patients to build confidence in defeating the disease. Provide continuous information support to eliminate uncertainty and anxiety.

For infants and young children, the most important thing is the psychological support of the parents of the children. Since the parents of the children in this case are non-medical staff, we have fully introduced the relevant knowledge of the disease to the parents in stages in easy-to-understand language. Special effect medicine, but still preventable and curable, eliminate parental tension and anxiety. Instruct parents on hand hygiene and wear masks; artificial feeding knowledge to teach, wash hands before and after breastfeeding, the temperature of milk powder is 40 ～ 50 ℃, the temperature is too high, it will destroy the nutritional content of milk powder; The technique and method of patting the back; pay attention to the water temperature when bathing the infant, increase or decrease the clothes appropriately according to the temperature change, and prevent other infections. Health education will be followed throughout the hospitalization and follow-up after discharge.

2.4. Health guidance for discharged patients

According to the requirements, it is recommended that isolation management and health monitoring should be continued, wear masks, live conditionally in a well-ventilated single room, reduce close contact with family members, share meals, do hand hygiene, and avoid going out.The retesting pharyngeal swab virus nucleic acid test was negative on February 3, 5, and 9 of the infant. The feces, urine, and sputum of the infant were collected for nucleic acid detection on February 5. The results showed that the urine was negative and the stool and sputum were positive. The fecal nucleic acid of the infant was positive on February 9. Meet the normal temperature for more than 3 days, respiratory symptoms improved significantly, two consecutive pharyngeal swab respiratory pathogen nucleic acid test negative discharge standard, the patient was cured and discharged on February 11. The grandmather took care of her after discharge (the infant ’s grandmather’s throat swab specimens were negative for nucleic acid when she was admitted to the hospital on January 26, and the 14-day isolation period had passed). On February 13, the grandmother had fever and CT showed novel coronary pneumonia and was isolated for treatment. The throat swabs of the infant were negative again, and the stool nucleic acid test was still positive.

3. Discussion

According to the epidemiological history of the infant (On the evening of January 21, the patient and her parents and grandparents drove from Xiaogan City, Hubei Province to Haikou, concentrated in a hotel to observe and live in isolation), and the clinical manifestations (fever, cough, spitting, low peripheral blood leukocyte, chest X-ray film showing slightly thickened right lung texture, like a bit of shadow), and throat swab detection of the novel coronavirus nucleic acid was positive, and the diagnosis was common COVID-19 [3]. With the outbreak peak and more areas carrying out pathogen detection, the number of reported cases of children's covid-19 has increased significantly, which has attracted attention from all parties. It is very important to identify early cases and observe and treat them in time [4-5]. Novel coronavirus pneumonia prevention and control work for children and pregnant women has been released recently by the national health and Health Committee. It is clear that "children and pregnant women are susceptible populations of novel coronavirus pneumonia". Novel coronavirus is also susceptible to all kinds of age, but the susceptibility varies with children. Novel coronavirus pneumonia is very important novel coronavirus pneumonia. The nursing strategy of adult novel coronavirus pneumonia has been reported. However, [6-8] has not been reported in children. The 8 nursing points novel coronavirus infected by the Chinese Nursing Association is available for reference [9].

This 3-month-old common COVID-19 patient had a good prognosis and was cured and discharged, suggesting that for patients with young age, timely and effective treatment combined with scientific nursing have positive significance for the outcome of the disease, mainly for the following reasons: (1) Infants have poor resistance. Good environmental care and nosocomial infection protection can reduce the incidence of cross-infection; (2) When children have coughing and other respiratory symptoms, they can be treated with atomization and sputum discharge to help reducind symptoms, keep the airway clear; (3) Strictly monitor the changes in the patient's vital signs, timely detect the patient's condition changes and intervene.

In this case, the infant led a family cluster outbreak, of the 5 people in this family, 4 were detected and reported as confirmed COVID-19 positive, indicating that family is highly contagious after exposure, and personal protection and quarantine of close contacts require special attention. In particular, it should be emphasized that the accompanying family members of children must strictly implement effective personal protection, wear masks, wear longsleeved clothing, and pay attention to hand hygiene to avoid infection caused by close contact. Strict visitation and escort system, in principle, visitation and escort are not allowed, but each hospital should fully evaluate the age span of children admitted, differences in care needs, children's compliance with treatment, the allocation of nursing human resources, and possible secondary Comprehensive assessment of risks and hazards.

This article summarizes the nursing experience of the first confirmed infant with COVID-19 (3-month-old infant) in Hainan Province. On the basis of conventional anti-viral, anti-infection and nebulization treatment, strengthen infection protection and management, dilute sputum, keep the airway clear, pat the back of the infant, suction sputum, clean up respiratory secretions in time, and relieve the respiratory symptoms. The nursing process is very important for the outcome of the disease. At the same time, we also carried out nursing interventions such as feeding guidance, isolation protection and health education for babies younger than months. During the hospitalization of the infant, the family's accompany and the risk assessment of infection are the inadequacies we have done. In future work, we should further summarize experience and strictly control the visitation and accompanying systems and standards for patients with infectious diseases.