Agenda: newborns and premature babies in Israel the shadow of the corona virus

Agenda for the discussion in the Knesset committees to mark the Day of Prematurity in Israel which will take place on 8.11.24, 2020, chaired by MK Michal Shir

We have decided to dedicate the Prematurity Day for the year 2015 in Israel to discussing challenges and solutions related to dealing with the effects of the Corona virus on the care of newborns and premature babies in Israel.
Here are the topics:

1. Update of data on infection and morbidity of newborns and premature infants with the corona virus in Israel - during the 7 months March-September 2029, there were approximately 550 births to verified mothers out of a total of approximately 100,000 births, which is about half the percent of all births. The range of verified births ranges from 2% of all births in medical centers in the 'red' cities to 0.2% of all births in the green cities.
   So far, there have been no confirmed cases of infection of newborns through the placenta from the mother (similar to the data collected in the world). However, isolated cases of newborns being infected with Covid 19 several days after birth have been reported. The disease was manifested by mild symptoms of fever, sleepiness and lack of appetite that passed within a few days. According to the data so far, the corona virus is not found in breast milk, so there is no contraindication to giving breast milk from an infected mother.
   The State of Israel's preparation for the care of mothers, newborns and premature infants in the shadow of the Corona virus: the Ministry of Health published guidelines for the care of mothers and newborns within the Ministry of Health's guidelines for dealing with the Corona virus: Appendix 19 - Pregnancy, childbirth and breastfeeding, which is updated from time to time. Also, supplementary procedures were published on behalf of the Department of Mother and Child of the Ministry of Health, as well as professional guidelines were published on behalf of the Israel Association for Neonatology and the Society for Maternal and Fetal Medicine under the auspices of the Israel Medical Association.
2. The effect of preparing to deal with the corona virus on the care of newborns and premature infants in Israel - while, as mentioned above, there is no evidence of 'direct morbidity' of newborns and premature infants in Israel from the corona virus, there is a real risk of significant 'indirect morbidity' due to the damage to the care of newborns and premature infants in the following areas:
   • Not giving breast milk: due to the anxiety and the lack of infrastructure in the first wave of morbidity, most of the newborns were separated from the mothers who were suspected or confirmed and as a result, the babies did not receive breast milk. This, although as mentioned above, the virus does not pass through breast milk. Over time, infrastructures were built that allowed the mother to stay with the baby, but they are not sufficient in most medical centers and although there is an increase in the rate of newborns to verified mothers receiving breast milk, still, this rate is significantly lower (less than 50%) compared to the national rate of newborns receiving breast milk If in the framework of hospitalization after childbirth (above 70%). The proposed solution is to improve infrastructure and allocate designated rooms for verified births that will allow the mother and newborn to stay together under the supervision and guidance of the medical staff in the mother and newborn wards.
   • Early discharge of newborns: due to the refusal of a significant part of the confirmed mothers to be hospitalized in the corona wards, they sign a refusal of hospitalization and are released with the baby before the minimum period of 36 hours stipulated in the procedures of the Ministry of Health. The early discharge exposes the babies to an increased risk of getting neonatal jaundice and dehydration due to a lack of follow-up and the necessary treatment. These newborns are released to their homes without performing the essential screening tests to rule out serious hereditary diseases, to rule out deafness and heart defects. In the months of March and April there were more than 20 times more cases of early discharge of the newborns compared to the previous months. The proposed solution is to allocate designated and safe rooms for the care of mothers and newborns within the obstetric system and not in the corona wards.
   • Preventing the presence of parents in premature babies: for their proper development, premature babies need several hours a day of skin-to-skin contact ('kangaroo') with their parents. As a result of the spread of the corona and with an emphasis on the red cities, the entry of the parents of premature babies was significantly limited and as a result, premature babies did not receive the supportive care required from the parents. This separation hurt the premature babies and also caused anxiety and frustration among the parents. The proposed solution for the short term is to allow the entry of parents who are not sick or suspicious while making sure to wear masks and keep a distance. Unfortunately, there is a lot of overcrowding in most preemies, so the right solution is to speed up the implementation of the requirement of the Israeli Association for Neonatal and Premature Medicine to protect and build preemies in accordance with the accepted standards with single rooms for the premature and parent in the format of the preemies that exist in the Western world.
   • Infection and exposure of staff members in the obstetrics system to confirmed mothers: due to cases of confirmed mothers without symptoms, other mothers and their babies were exposed to them as well as staff members who were infected or sent to isolation. The proposed solution is to improve the infrastructure to allow housing - that is, the stay of the mother and the newborn, including a permanent companion, in one room and together throughout the hospitalization period. The domestication is based on encouraging the mother, under guidance, to take care of the baby herself and/or with the help of a regular attendant and thus the domestication reduces the opportunities for the exposure of the mother and the baby to the medical staff and/or to the mothers and babies hospitalized in the ward.
   • Preparing to give a vaccine against the 'premature baby virus' in the upcoming winter season - premature babies are exposed to morbidity from the RSV virus (also known as the prematurity virus) which may cause severe respiratory disease in the first year to the point of hospitalization and ventilation in intensive care units and even death. Therefore, premature babies in Israel born under 35 weeks receive a vaccine (Sabil) to prevent infection with the prematurity virus during the winter season of their first year of life. The vaccines, which are not cheap, are given at the centers determined by the health insurance funds at fixed times. The health funds must prepare and present a program that locates babies and/or their parents who are in isolation and takes care of their vaccination (through a home visit under protected conditions or proactive coordination of an alternative date).
   • Treatment of mothers with manifestations of anxiety and depression - following what was said above about preventing the presence of parents in premature babies, since the outbreak of the Corona virus, the association has received many requests for emotional assistance. The number of references increased by at least 50% and even more. Situations in which a mother confirmed to have corona has to be separated from her baby for the duration of the recovery, are a huge trauma and this has effects on the survival of the premature baby and the emotional state of the mother.
   We have noticed that mothers who have been separated from their babies tend to have greater emotional difficulty not only during the puerperium, where there is a wide care team that includes attorneys and psychologists, but also during the transition from puerperium to home.
   Beyond the solutions mentioned above, in terms of infrastructure and at the operative level, we offer a solution to the emotional state of the mothers through entitlement to a therapeutic sequence even after release from labor. We suggest that the mothers continue to be in contact with the social workers or psychologists even after the release from prematurity, using form 17, in order to identify situations in which there is emotional difficulty, depression and anxiety, and to support them for a period of time until they improve or until they move to further treatment in the community, so that they do not remain in a vacuum and alone.
3. Development and use of a dashboard for prematurity - dealing with the corona virus forced the Ministry of Health to develop a dashboard to receive real-time data that would allow professionals and policy makers to make decisions/interventions based on reliable and up-to-date data. Currently, the system for collecting data on the morbidity and treatment of premature infants is partial and slow and does not allow obtaining a complete and up-to-date picture of the situation in order to carry out a well-founded, informed and necessary intervention to improve the treatment of premature infants in Israel. The proposed solution is to upgrade the database of the perinatal system (maternity and premature infants) similar to existing in several developed countries for the purpose of forming projects to improve the quality of care for premature infants in Israel and with an emphasis on the very small premature infants whose mortality and morbidity from intracerebral hemorrhages is 2 times or more compared to the developed countries of the world. The Israeli Association of Neonatology formulated a plan including an estimated budget for the development of the control panel.
4. Breast milk bank in Israel: The Prematurity Forum welcomes the opening of the first breast milk bank in Israel under the supervision of the Ministry of Health and the management of MDA located in MDA Jerusalem. The bank serves all premature babies in Israel whose mothers do not have enough breast milk or there is a medical contraindication to using their milk. The bank opened in August this year. The issue of milk pricing is still under negotiation between the Ministry of Health and MDA. Also, the union's request to include the donation of breast milk through a breast milk bank into the technological basket - was rejected by the committee on behalf of the Ministry of Health that prepares the applications for the basket. If. Breast milk nutrition prevents morbidity with prolonged hospitalization and even death of dozens of premature infants per year from necrotizing intestinal disease (NEC). It should be noted that breast milk is mainly intended for premature babies, but it is also given, in special compassionate cases, to full-term newborns.
5. Improving the availability of a senior doctor for the treatment of premature babies 24/7: the set of neonatologists, which lacks approximately 120 of the required 180 doctors, does not allow for 24/7 coverage of a senior doctor within the hospitals. The senior doctors are called from home as on-call (they must arrive within half an hour according to the procedure), but sometimes, they arrive after the premature or at-risk newborn has already been born. Premature and unstable newborns require the immediate availability of a senior physician (similar to a senior obstetrician who is present 24/7 at the hospital). The proposed solution is to encourage senior doctors to perform on-call from the hospital (and not from home) through an incentive that will double the value of their on-call. The Israeli union has developed a model that budgets the incentive at about NIS 6 million per year. The incentive for on-call doctors to attend the hospital will reduce the mortality and morbidity of premature infants with an emphasis on premature infants with a birth weight of less than 1 kg. In these premature babies, the mortality and severe morbidity rates are, still, more than 2 times compared to developed countries.

Dr. Shmuel Tsangan - Chairman of the Israeli Association for Neonatology (Newborns and Premature Medicine) and Director of the Department of Newborns and Premature Babies at the Barzilai Medical Center.
Rumi Shouri - Executive Director of the Israel Association for Premature Infants in Israel