GUIDELINES FOR H1N1 / SEASONAL FLU MANAGEMENT IN THE NEWBORN UNITS
BETH ISRAEL DEACONESS MEDICAL CENTER
2009-2010
INTRODUCTION
Background
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Influenza-like Illness (ILI) is defined as fever greater than 100°F and recent onset of cough or
sore throat.
Incubation period for influenza is 1-4 days. Virus shedding generally begins 1 day prior to onset
of symptoms, and can persist for 5 to 7 days or longer.
Transplacental transmission of influenza virus has not been documented.
Breast milk is not thought to be a potential source of influenza virus infections.
Droplet precautions include private room with closed door and use of mask with visor by staff
and visitors.
Guidelines for NICU management of infants exposed to ILI are designed to minimize risk to that
infant as well as risk to other infants in the NICU.
Visiting Guidelines
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In the NICU, children under the age of 12 may not visit. In post-partum, well siblings of
newborns may visit; other children under the age of 12 may not visit.
All visitors, including parents, will be screened by staff at each visit using BIDMC’s standard
influenza screening questions asking about potential flu symptoms.
Visitors who have had a fever and either cough or sore throat within the past 7 days may not
visit until 5 days after their symptoms began or 24 hours after their last fever without feverreducing medications. Visitors with fever in the past 7 days and exposure to someone with flu
symptoms may not visit until 10 days from their last exposure.
Family and visitors to the NICU without fever in the past 7 days but who have cough, sore
throat, or exposure to someone with fever and cough or sore throat should wear a mask to visit.
Visitors to the NICU with fever in the past 7 days but no cough, sore throat, or exposure to a
person with fever and cough or sore throat should wear a mask to visit.
Visitors cleared to visit will receive a sticker that indicates their clearance for that day.
Discretion should be used for visitors with significant signs of illness or exposures other than
those identified by the screening questions; in certain situations, avoiding visiting may still be
prudent.
Visiting by non-family members should be discouraged.
Visitors who have received the live attenuated influenza vaccine (nasal vaccine) for seasonal
influenza or for H1N1 influenza may visit.
Visitors to infants on droplet precautions must wear mask with visor.
Careful hand hygiene should be encouraged at all times.
NEWBORN NURSERY AND POST-PARTUM
Management of Infants Born to Mothers with Influenza-Like Illness
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Infants born to mothers with influenza-like illness should be cohorted with their mother, who
will be on droplet precautions.
o Infants should remain in mother’s room at all times. Infants should not be brought to
newborn nursery for assessments or procedures.
o Mothers should wear face mask at all times when within 6 feet of their infant (ie when
holding, feeding, or caring for their infant). As much care as possible should be provided
by mother’s partner or other well family member.
o Mothers should perform careful hand hygiene prior to handling their infant.
o Mothers should wear a new hospital gown prior to nursing or holding their infant.
o Sick family members and friends should not visit.
o Infant and mother should be in isolation and on droplet precautions; staff should wear
masks to enter room.
If the mother’s family member (s) has influenza-like illness, she has been exposed, even if she is
currently asymptomatic, and the entire family unit is placed on droplet precautions. Mother
and her significant other should wear a face mask when within 6 feet of the infant.
If mother is too ill to care for her infant herself and there is no healthy family member available,
the infant should be cared for in the newborn nursery, in an incubator 6 feet from other infants,
and on droplet precautions, with staff wearing mask and gloves and performing hand hygiene
before and after contact.
In other rare situations in which infant must be brought to newborn nursery, infant should be
maintained in droplet isolation as described above.
NEONATAL INTENSIVE CARE UNIT
Management of Infants Born to Mothers with Influenza-Like Illness
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(Note: If Mothers’ partner has ILI, he/she will have worn a mask at delivery and will not be
allowed to visit infant until he/she is 5 days after onset of symptoms or 24 hours afebrile off of
antipyretics, whichever is longer. As long as she remains afebrile, mother would be allowed to
visit with a mask for 10 days after her last exposure to her partner when he/she was febrile.)
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Infants directly admitted to NICU from L&D immediately after delivery:
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Newborns that are expected to be admitted to the NICU should be brought from L&D to
the NICU without close or direct physical contact with the mother. These infants then
do not require isolation.
 Rationale: transplacental transmission of influenza virus has not been shown.
Avoiding direct contact of the newborn with the mother will minimize the
opportunity for transmission.
Mothers should not be allowed to visit until 5 days after onset of symptoms or 24 hours
after their fever resolves off antipyretics, whichever is longer.
In certain situations, allowing parental visiting will be necessary. These could include an
infant being prepared for imminent discharge or an infant who is critically ill. In these
situations, at the discretion of the nurse manager and attending physician, parental
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visiting can be allowed, and the infants should be placed in isolation and on droplet
precautions (see below).
Infants who are known in advance to need temporary NICU admission (for sepsis evals, etc)
should also be brought from L&D to the NICU without close or direct physical contact with the
mother, so that they will not require isolation. They may then be returned to the mother in L&D
or on her postpartum floor.
Infants admitted to NICU from post-partum, or after direct contact with mother:
o Infants should be placed on droplet precautions in a private room (see below).
o Mothers should not be allowed to visit until 5 days after onset of symptoms or 24 hours
after their fever resolves off antipyretics, whichever is longer. Afebrile partners may
visit with mask use for at least 10 days past their last exposure to the mother when she
was febrile.
o Isolation and droplet precautions should be continued for 10 days after the last
exposure to the mother while she was febrile.
o In certain situations, allowing parental visiting will be necessary. These could include an
infant being prepared for imminent discharge or an infant who is critically ill. In these
situations, at the discretion of the nurse manager and attending physician, parental
visiting can be allowed, and the infants should be placed in isolation and on droplet
precautions (see “Management of Infants in Isolation and on Droplet Precautions”
below).
Management of Infants in the NICU whose Parents Develop ILI
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If infant had contact with parent in the 24-hour period prior to onset of symptoms, infant should
be placed on droplet precautions in a private room.
Parent with ILI should not be allowed to visit until (1) 5 days after onset of symptoms or 24
hours after their fever resolves off antipyretics, whichever is longer.
In certain situations, allowing parental visiting will be necessary. These could include an infant
being prepared for imminent discharge or an infant who is critically ill. In these situations, at the
discretion of the nurse manager and attending physician, parental visiting can be allowed, and
the infants should be placed in isolation and on droplet precautions (see “Management of
Infants in Isolation and on Droplet Precautions” below).
Management of Infants in Isolation and on Droplet Precautions
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Infants should be placed in private room with door kept closed.
Careful hand hygiene should be performed.
Staff should wear mask with visor or protective eyewear.
Parents with ILI who are being allowed to visit should wear mask with visor, and should wear a
new hospital gown prior to holding infant.
Visitors other than parents should be discouraged. All visitors should wear masks with visors.
For aerosol-generating procedures, staff should wear additional including gowns, gloves, N95
respirator, and protective eyewear. These procedures include intubation, extubation, CPAP, and
open suctioning of the airways (without the inline closed suction catheter).
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Droplet precautions should continue until discharge or until 10 days after last exposure to
person with ILI during their illness.
Management of Infant in NICU with Possible Influenza Infection
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Signs and symptoms of influenza infection in newborns can be nonspecific. A low threshold for
considering influenza infection should be maintained in infants with exposures to individuals
with ILI.
Testing for seasonal flu and H1N1 can be performed by nasopharyngeal flocked swab or tracheal
aspirate performed by respiratory therapy and sent for DFA for Influenza A/B; tests positive for
Influenza A should be sent for confirmatory testing for H1N1 by discussion with pathology
resident in Microbiology laboratory.
No recommendations exist for use of antiviral medications in infants under 3 months of age,
though the unknown risk/benefit ratio for antivirals in this age group favors supportive care over
medication. Infectious Disease consultation should be considered.
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