The COVID-19 pandemic has complicated some of the routine ways respiratory therapists are able to provide care to children in the NICU/PICU.

By Lisa Spear

When a COVID-19-positive pregnant woman comes to Penn State Children’s Hospital in labor, she is rushed, not to a labor and delivery room, but to an intensive care surgical unit that has been converted to a makeshift coronavirus unit. 

A nurse in light blue scrubs catches her baby as a physician and respiratory therapist standby outside. Unless something goes wrong, the nurse will deliver the newborn alone. No family members will be present. The light blue scrubs are meant to communicate to everyone in the hospital that the clinician is caring only for COVID-19 patients. “Once you put on those light blue scrubs, you identify as a COVID nurse or a COVID respiratory therapist and from that point on, you are not permitted to touch another patient,” said Jennifer Erkinger, RRT, a respiratory therapist and clinical specialist at Penn State Children’s Hospital in Hershey.

After birth to a COVID-19-positive mother, a newborn is then slid into an isolette for transport to another hospital floor for isolation in a negative pressure room. Since the babies have their mother’s antibodies for at least the first 48 hours after birth, the clinicians must wait two days before administrating the coronavirus test. The babies stay in isolation until a negative result is produced. As a precaution, mothers are not permitted to see or hold their new babies until discharge from the hospital. 

This is just one example of how medical systems have developed new ways to cope with the coronavirus pandemic. Since the SARS-CoV-2 virus caught the world off guard, medical centers throughout the country have been forced to reinvent how they treat patients and how they protect their staff. 

“The most important thing in my mind, and I think, our leaderships’ minds, is how do we take care of our staff? Taking care of the patients has always been a priority that never changed,” Erkinger said. “We’ve had some really awful viruses that we’ve seen at Hershey, so COVID didn’t scare some of us as much, but it did scare some of our staff, so our priority was making sure that they felt that we were taking care of them.” 

Hospital administrators rapidly developed new protocols and ramped up infection control procedures. In some instances, clinical team members, gowned in full protective equipment, even took the extra precaution of standing outside in the hallways or sometimes standing further away from patients, when possible. Sometimes, during aerosol generating procedures or open circuit high-flow nasal cannula therapy, social distance is not possible.

Erkinger said she has stood outside a number of deliveries to COVID-positive mothers. “If there were any issues, we were there, gowned and gloved, ready to go in and resuscitate the baby.” 

“Certainly things have changed due to COVID,” said Jennifer Mahone MHA, RRT-NPS, AE-C, a neonatal and pediatric clinical specialist and interim respiratory director with Tower Health system in Pennsylvania. “Myself and my other clinical specialist, we were constantly researching as new evidence or new guidelines were coming out from the CDC. We were constantly adapting to change and making sure that we had the supplies that we need.” 

At Penn State Children’s Hospital, clinicians try think of every possible COVID-related scenario to plan ahead, said Erkinger, but often times they have to figure out solutions in real-time. 

“Just delivering processes and medications couldn’t be done at all the same as we had been doing them for the last 100 years,” said Erkinger, who works as a manager at the children’s hospital. The biggest obstacle by far, she said, was always the reoccurring question of “How do we keep these kids safe and our staff safe at the same time?”

Most medical centers, including the NICUs, have largely cut down on parental and family visitation, according to a paper coauthored by neonatologist Peter Murray, MD, an assistant professor of pediatrics at University of Virginia Health System in Charlottesville.1 “Although the COVID-19 pandemic has largely not clinically affected infants in neonatal intensive care units around the globe, it has affected how care is provided,” Murray wrote. 

To date, neonatal infection is uncommon and is associated with favorable outcomes. The reason why infants exhibit milder symptoms is still undetermined. Nonetheless, the risk of severe illness in young children does exist, according to a paper published in June in The American Journal of Perinatology.2

Many children who test positive for COVID-19 don’t have severe symptoms. Some may have high fevers, diarrhea, and dehydration. Others may develop Kawasaki disease, an inflammatory illness. Overall, Erkinger said, there have been very few child deaths from COVID and none reported where she works at Penn State Children’s Hospital. Many of the pediatric patients who come through the hospital are admitted for only 24 to 48 hours before being discharged. “Every child seemed to react a little differently from COVID, just like adults. Some people have it and don’t know they have it,” Erkinger said. 

It is now established that transmission from pregnant mother to baby during delivery is unlikely. Since March, up to 30 COVID-positive pregnant women have come through Penn State Children’s to deliver their babies and there’s been no reported cases of transmission to infants. 

According to the Perinatology papers’ authors, a team of international researchers, the current respiratory approach for infants with suspected or confirmed novel coronavirus infection is not evidence based, but it should incorporate all usual types of support, with the addition of viral filters, personal protective equipment, and placement of infants in isolation rooms. Since information is evolving rapidly, respiratory therapists should frequently check the medical literature for updates on how to best care for these patients, the authors suggested. 

At the start of the pandemic, nebulizers became a point of concern. Mahone’s team worked quickly to find a safe way to continue to use nebulizers with a filter or turning to vibrating mesh Aerogen nebulizers to prevent the spread of virus particles into the air. 

One of the most palpable changes in the neonatal and pediatric intensive care units at the hospital was the amped up protective gear and infection mitigation strategies, Erkinger explained.  

Respiratory therapists are now required to wear goggles and face shields every day. As a result of their strict adherence to new infection prevention protocols, none of the Penn State Children’s Hospital respiratory therapists became infected with the virus. 

While the extra PPE provides essential protection, it can also be cumbersome, and make it more difficult to work with tiny babies, said Erkinger. “Looking through the face shield, it can be very blurry,” she said. “…Learning how to treat patients with face shields and all that PPE is a huge challenge.” 

HEPA filters have become an essential tool in the fight against COVID-19. To stop the spread of the virus through aerosols, hospital administrators stocked up on these filters. All airway carts, crash carts, and delivery rooms were supplied with HEPA filters to ensure that every patients who needed resuscitation had a filter inline. “Everyone was carrying HEPA filters, we had to distribute so many of these HEPA filters, everywhere,” said Erkinger.

As patients were coming in, Penn State providers had to decide in real-time what to do. In one instance about two months ago, the transport team was called to pick up an asthmatic child in respiratory distress. The team found that the child was on a continuous albuterol nebulizer, an aerosol generating procedure, the clinicians decided to pull the child off of the medication while in transport to prevent the potential spread of the virus. The clinicians were able to successfully transition the child to non-arousal generating therapy. 

“There was constant text messaging among physicians, respiratory therapists and charge nurses,” Erkinger said. “I think the biggest challenging thing was that the processes would change every other day. We would figure something out, and would implement it and educate rapidly, and then two or three days later we would find out that there was something that we weren’t doing appropriately and we would have to change it up, and then we would have to reeducate.”


Lisa Spear is associate editor of RT magazine. For more information, contact [email protected].


  1. Murray PD, Swanson JR. Visitation restrictions: is it right and how do we support families in the NICU during COVID-19? Am. J. Perinatol 2020 Oct;40(10):1576-1581. 
  2. Shalish, W, Lakshminrusimha, S, Manzoni, P, Keszler, M, et al. COVID-19 and neonatal respiratory care: current evidence and practical approach. Am. J. Perinatol. 2020; 37(8):780–791.