COVID-19 and Neonates

COVID-19 and NEONATES:

COVID-19 Reference (Updated September 6, 2020)

Click here to access the comprehensive resource from Dr. Bernd S. Kamps and Dr. Christian Hoffmann summarizing weekly scientific updates on COVID-19,   This excellent reference provides information as it becomes available on what is known about the pathogenesis and transmission of the virus, an international timeline of COVID-19, how it presents in both adult and paediatric populations, and much more.  Click on specific sub-headings in the Table of Contents, to be re-directed to the relevant section of the text.

September 2, 2020 – Premature Births and Stillbirths 

  Article 1: Danish Premature Birth Rates During the COVID-19 Lockdown 

  • Lower rate of extremely premature children during the lockdown when compared to the corresponding mean rate for the same dates in the previous years
  • No significant difference was found between the lockdown period and gestational age categories  
  • Elements of the lockdown (reduced physical activity, for example) could be beneficial for reducing extreme prematurity  

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7421710/ 

 

Article 2: Change in the Incidence of Stillbirth and Preterm Delivery During the COVID-19 Pandemic 

  • Note: this research was performed in the UK 
  • The incidence of stillbirths was higher in the pandemic period than the pre-pandemic period (none related to COVID-19 infections) 
  • None of the stillbirths during the pandemic, however, were born to women with confirmed COVID-19 
  • Increase in stillbirths may related to indirect effects of the pandemic such as reluctance to going to hospital when needed (ex. Reduced fetal movements) or fear of contracting infection 

Link: https://jamanetwork.com/journals/jama/articlepdf/2768389/jama_khalil_2020_ld_200076_1597432990.501.pdf 

 

March 26, 2020 – What we know

As novel coronavirus (SARS-CoV-2/ COVID-19) continues to sweep across the world, the literature describing the paediatric presentation of this pandemic remains scarce. In Wuhan, China patients < 1 year of age had the highest percentage of critical cases in the pediatric population1. Therefore, it is imperative to reduce the risk of transmission to this vulnerable group and remain up-to-date on the current guidelines.

Presentation:

While the spectrum of clinical manifestations has yet to be fully described, adults and children both typically present with varying degrees of respiratory illness and gastrointestinal upset. The majority of pediatric cases present mild, with potential symptoms including cough, nasal congestion, rhinorrhea, and sore throat2.

Vertical Transmission:

There are no current reports of vertical transmission of COVID-193. In Huijun, Chen et al investigated the potential intrauterine vertical transmission of COVID-19. Samples of the amniotic fluid, cord blood, neonatal throat swab and breastmilk were taken at the time of delivery of six women with confirmed COVID-191. All tests remained negative for COVID-19, suggesting intra-uterine transmission of the virus does not occur1. Although, some have suggested that temporarily separating the mother and baby after birth (for example, room separation) could aid to further reduce the risk of transmission4.

Breastfeeding:

The World Health Organization (WHO) currently states that it is safe for mothers with COVID-19 to breastfeed as long as they practice the necessary precautions5 which include wearing a surgical mask, washing their hands and breast before and after they breastfeed, as well as thoroughly cleaning surfaces and objects with which they have come into contact5. The American College of Obstetricians and Gynaecologists adds that if a woman is using a manual or electric breast pump, proper cleaning measures of both the pump and the mothers hands must be followed and encourages having someone who is well feed the baby4.

References:
1. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet. 2020;395(10226):809-815.
2. Coronavirus Disease 2019 (COVID-19) [Internet]. Centers for Disease Control and Prevention. 2020 [cited 24 March 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/pediatric-hcp.html
3. Cruz A, Zeichner S. COVID-19 in children: initial characterization of the pediatric disease. Pediatrics. 2020; doi: 10.1542/peds.2020-0834
4. Novel Coronavirus 2019 (COVID-19) [Internet]. Acog.org. 2020 [cited 24 March 2020]. Available from: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019
5. WHO, Department of Communications, Maternal, Newborn, Child and Adolescent Health, and Ageing. Q and A on COVID-19 https://www.who.int/news-room/q-a-detail/q-a-on-covid-19-pregnancy-childbirth-and-breastfeeding Accessed March 2020.
 

Authored by Maria Casalino. Edited by Dr. Elizabeth Mancuso.

 

 

 

 

 

Recommendations

Paediatric COVID-19 Literature Review Update

Neonatal Resuscitation and Postresuscitation Care of Infants Born to Mothers with Suspected or Confirmed SARS-CoV-2 Infection

 

This article discussed the following key points:

Delivery of a newborn to a COVID-19 Positive Mother

    • NY State currently allows one support person present during the time of delivery – they must be asymptomatic with a negative COVID-19 test
    • There is not enough current evidence to support or rebut antenatal steroids in COVID-19 positive mothers awaiting preterm delivery
    • WHO recommends that “mothers and infants with suspected or confirmed COVID-19 have the option to remain together with skin-skin contact, especially following delivery”
    • Immediate cord clamping should be performed on mothers with suspected or confirmed COVID-19
    • 20-60 minutes before delivery of a newborn to a COVID-19 positive mother, the neonatology team should be informed
    • The neonatology teams should be prepared with a PPE grab and go kit

 

Vertical Transmission & Breastfeeding

    • No current cases that support vertical transmission
    • Recent reports show elevated COVID-19 IgM in newborns born to mothers with confirmed COVID-19 but more evidence needed
    • Delayed cord clamping does not increase risk of vertical transmission (obstetric provider should hold baby throughout delayed cord clamping)
    • No reports of SARS-COV-2 spread through breastmilk – WHO currently supports continuation of breastfeeding with essential hygienic practices and protocols
    • SARS-COV-2 antibodies have been discovered in breastmilk

 

Neonatal Resuscitation

    • Neonatal resuscitators should be held in the delivery room
    • The neonatal resuscitation team should be accessible outside the delivery room, if needed
    • The optimal location for neonatal resuscitation remains unclear – it may take place in the delivery room (must remain 6 feet away from the mother with a physical barrier such as a curtain) or in an alternative room
    • Newborn resuscitation protocols should follow AAP and NRP recommended parameters – it is important that the correct PPE be worn at all times
    • The most experienced provider should perform intubation and other procedures to limit aerosol generation

 

Post Resuscitation Care

    • Post resuscitation, the newborn should be transported in a closed isolette and isolated in a negative pressure room
    • Having a specialized team that cares for babies born to COVID-19 positive mothers could aid to minimize spread to other healthcare workers
    • Newborns to COVID-19 positive mothers should be tested at or beyond 24 hours
    • A chest X-ray is indicated in COVID-19 positive newborns that display respiratory symptoms
    • Chest x-rays demonstrate signs of pneumonia
    • Typical Lab analysis shows leukocytosis, lymphopenia, thrombocytopenia and elevated creatinine kinase-MB fraction
    • There is no current evidence that demonstrates increased outcomes upon the administration of Immunoglobulins, antivirals or steroids
    • A healthy caregiver may care for the newborn until the mother is afebrile (without antipyretics) and has two negative tests for SARS-COV-2 at least 24 hours apart

 

The possibility of infection from SARS-COV-2 should be considered in the ill infant for the foreseeable future

 

Click here for the full article: Chandrasekharan, P., Vento, M., Trevisanuto, D., Partridge, E., Underwood, M.A., Wiedeman, J., Katheria, A. and Lakshminrusimha, S., 2020. Neonatal Resuscitation and Postresuscitation Care of Infants Born to Mothers with Suspected or Confirmed SARS-CoV-2 Infection. American Journal of Perinatology.

Clinical and CT features in pediatric patients with COVID‐19 infection: Different points from adults

 

This article discussed the following key points:

  • The most common presenting symptoms were fever and cough
  • Procalcitonin (PCT) was elevated in 80% of cases whether or not coinfection existed, which is uncommon in the adult population.
  • Majority of patients had a normal WBC count
  • On CT, the most common finding was unilateral or bilateral subpleural ground‐glass opacities, and consolidations with surrounding halo sign. “As consolidations with surrounding halo sign account for up to 50% cases, they should be considered as typical signs in pediatric patients.”
  • Pleural effusions were not seen on CT

 

Click here for the full article: Xia, W., Shao, J., Guo, Y., Peng, X., Li, Z. and Hu, D., 2020. Clinical and CT features in pediatric patients with COVID‐19 infection: Different points from adults. Pediatric Pulmonology.

A Well Infant With Coronavirus Disease 2019 With High Viral Load

 

This is an interesting case study of a 6 month old infant with confirmed SARS COV-2 in Singapore.

Key points:

  • The infant was brought in for isolation due to both of his parents having tested positive for SARS COV-2
  • Presented asymptomatically, afebrile, with no tachypnoea and an oxygen saturation of 98%
  • A nasopharyngeal swab was performed on the infant and he tested positively for SARS COV-2
  • He remained asymptomatic throughout the his admission  
  • His stool tested positive for SARS-COV-2 on admission day 9
  • This opens up the possibility of a much higher number of pediatric SARS-COV-2 cases in the community that remain asymptomatic as compared to the reported confirmed cases

 

Click here for the full article: Kam, K.Q., Yung, C.F., Cui, L., Lin Tzer Pin, R., Mak, T.M., Maiwald, M., Li, J., Chong, C.Y., Nadua, K., Tan, N.W.H. and Thoon, K.C., 2020. A well infant with coronavirus disease 2019 (COVID-19) with high viral load. Clinical Infectious Diseases.