The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: 1476-7058 (Print) 1476-4954 (Online) Journal homepage: https://www.tandfonline.com/loi/ijmf20

COVID 19 in neonates

Venkat Reddy Kallem & Deepak Sharma

To cite this article: Venkat Reddy Kallem & Deepak Sharma (2020): COVID 19 in neonates, The
Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2020.1759542

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Published online: 18 May 2020.

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THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
https://doi.org/10.1080/14767058.2020.1759542

REVIEW ARTICLE

COVID 19 in neonates
Venkat Reddy Kallema and Deepak Sharmab
a
Paramitha Children Hospital, Hyderabad, India; bDepartment of Neonatology, National Institute of Medical Science, Jaipur, India

ABSTRACT ARTICLE HISTORY

Corona virus disease 2019 started in December 2019 as an outbreak of unexplained pneumonias Received 15 April 2020
in Wuhan, a city in Hubei province of China. This illness emerged as an epidemic in China and Accepted 20 April 2020
later spread to almost all countries over the globe except Antarctica. This is caused by a beta
KEYWORDS
Corona virus, which is genetically similar to SARS virus. The predominant mode of transmission
Corona virus disease 2019;
is via droplet spread, when the infected person coughs, sneezes or talks the virus is released in pregnant mother; newborn;
the respiratory secretions. As there are only a few cases of COVID 19 in neonates, there is no SARS-CoV-2
convincing evidence to support the possibility of vertical transmission. Clinical presentation in
neonates is nonspecific, commonly observed are temperature instability, respiratory distress,
poor feeding, lethargy, vomiting and diarrhea. Laboratory examinations may be nonspecific.
Definitive test for 2019-nCoV is the detection of viral nucleic acid by real-time fluorescence poly-
merase chain reaction (RT-PCR). Suspected and confirmed COVID positive mothers should be
delivered in separate delivery rooms and operation theaters. Since there is no approved treat-
ment or drug for this disease, prevention of infection and breaking the chain of transmission
plays a crucial role.

Introduction neonates. In this article we have tried to synthesize

Corona virus disease 2019 (COVID 19) is a respiratory
tract infection caused by an emerging virus belonging
to the group of corona viruses [1–3]. This was named
initially as novel corona virus 2019 (2019-nCoV) and
later it has been changed to Severe Acute Respiratory
Syndrome Corona Virus 2 (SARS-CoV-2) [4]. It started
in the initial days of December 2019 as an outbreak of
unexplained pneumonias in Wuhan, a city in Hubei
province of China [3]. This illness emerged as an epi-
demic in China and later spread to almost all countries
over the globe except Antarctica [5]. So, Word Health
Organization (WHO) declared COVID 19 as a pandemic
on 11 March 2020 [6]. Till date (14/04/2020), 1,939,809
positive cases and 120,899 deaths have been reported
worldwide and the number is increasing continuously
[5]. In general population, the majority of patients
with COVID 19 develop mild or uncomplicated illness,
around 14% develop severe disease requiring hospital-
ization and oxygen support, around 5% may require
intensive care support [7]. There is a paucity of data
on clinical presentation, treatment and outcome in
special population, such as pregnant women and
the available literature on COVID 19 in neonates.
Etiopathogenesis
Corona viruses are large enveloped positive sense RNA
viruses belonging to family called Coronaviridae [8].
These are subdivided into four genera (Alpha, Beta,
Gamma and Delta), of these Alpha and Beta groups
lead to mild respiratory infections in humans [8].
SARS-CoV-2 is a beta corona virus which is genetically
similar to SARS virus [7]. SARS-CoV-2 is inactivated by
chemical disinfectants like 62–71% ethanol, 0.5%
hydrogen peroxide or 0.1% sodium hypochlorite
within 1 min [9]. SARS-CoV-2 enters the cells by attach-
ing to the angiotensin converting enzyme 2 (ACE-2)
receptor on the cells. This receptor is highly expressed
on Type 2 alveolar cells in the lung, and researchers
also found these receptors on esophageal epithelial
cells, ileal and colonic enterocytes [10,11].
Modes of transmission
The predominant mode of transmission is via droplet
spread, when the infected person coughs, sneezes or

CONTACT Deepak Sharma dr.deepak.rohtak@gmail.com Consultant Neonatologist, National Institute of Medical Science, Jaipur, Rajasthan, India
Due to the urgent and developing nature of the topic, this paper was accepted after an expedited peer review process. For more information about the
process, please refer to the instructions for authors.
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 V. R. KALLEM AND D. SHARMA
talks, the virus is released in the respiratory secretions.
These droplets may come in direct contact with the
mucous membranes and cause infection. The virus in
the droplets can stay on the different surfaces for a
variable period of time, maximum being nine days [9].
So touching an infected surface and then touching of
eyes, mouth or nose can cause infection. SARS-CoV-2
was found in fecal samples of some patients in United
states and China, so the possibility of feco-oral trans-
mission cannot be ignored, although this has not
been proved till date [12].
As there are only few cases of COVID 19 in neo-
nates, there is no convincing evidence to support the
possibility of vertical transmission. Many reports from
China did not find any evidence of vertical transmis-
sion and various sample (amniotic fluid, cord blood,
neonatal throat swabs, placental swabs, genital fluid
and breast milk samples) from infected mothers who
were tested negative for the virus [13–18]. But, a
recent report described a mother–infant dyad in which
the infant born to a COVID 19 positive mother was
found to have SARS-CoV-2 IgM in serum at birth
(which represents neonatal immune response to in
utero infection) [19].
Clinical manifestations
Though COVID 19 cases crossed 1 million mark glo-
bally, there are very limited number of confirmed neo-
natal cases. Clinical presentation in neonates is
nonspecific, so suspected neonates should be closely
monitored for vitals, respiratory and gastrointestinal
symptoms. Commonly observed symptoms are tem-
perature instability, respiratory distress, poor feeding,
lethargy, vomiting and diarrhea [16].
In a retrospective review of nine pregnant women
by Chen et al., none of the newborn was tested posi-
tive for SARS-CoV-2 [13]. Zhu et al. reported 10 preg-
nant women who were tested positive for COVID 19.
All the neonates were negative for SARS-CoV-2 RNA
test. Out of them one neonate had radiological picture
(CT) showing ground glass opacities, which is a typical
finding seen in adults. Clinically, neonate had mild
respiratory distress which did not require intubation
and mechanical ventilation [15]. Xiaoyuan et al. and
Wang et al. reported a total of five confirmed neonatal
cases, of this one neonate presented at 30 h of life. All
of them had nonspecific clinical symptoms in the form
of fever, lethargy, poor feeding, vomiting and sneez-
ing. None of them required intubation and recovered
with supportive care [20,21]. Zeng et al. followed 33
neonates born to COVID 19 positive mothers and
three of them were tested positive for COVID 19. Two
neonates born at term gestation and one born pre-
term were positive. The various symptoms of three
neonates were fever, pneumonia, respiratory distress
syndrome, shortness of breath, cyanosis and feeding
intolerance. All three neonates were discharged in
well condition [22].
Diagnosis
Laboratory examinations may be nonspecific.
Complete blood count may show normal or decreased
leukocyte counts, decreased lymphocyte count and
mild thrombocytopenia. Various enzymes level is
found to be elevated, including creatine kinase, alka-
line phosphatase, alanine aminotransferase, aspartate
aminotransferase, and lactate dehydrogenase [16].
Definitive test for 2019-nCoV is detection of viral
nucleic acid by real-time fluorescence polymerase
chain reaction (RT-PCR) in the samples collected from
upper respiratory tract (URT; nasopharyngeal and oro-
pharyngeal), the lower respiratory tract (LRT; endo-
tracheal aspirate or bronchoalveolar lavage), the blood
and the stool [16].
A suspect case is defined as a neonate born to the
mother with a history of 2019-nCoV infection between
14 days before delivery and 28 days after delivery, or
the neonate directly exposed to those infected with
2019-nCoV (including family members, caregivers,
medical staff, and visitors) [16]. Diagnosis of 2019-
nCoV infection can be confirmed if any one of the fol-
lowing etiological criteria is met: respiratory tract or
blood specimens tested by RT-PCR are positive for
2019-nCoV nucleic acid; or virus gene sequencing of
the respiratory tract or blood specimens is highly
homologous to that of the known 2019-nCoV speci-
mens [16].
Delivery room management
In this crisis situation, triaging of the patients based
on clinical case definition as normal and suspected is
very important for proper utilization of human resour-
ces [23]. Suspected and confirmed COVID positive
mothers should be delivered in separate delivery
rooms and operation theaters [24]. In addition to
standard universal precautions, the health care person-
nel should use personal protection equipment (PPE) to
prevent acquiring infection through respiratory drop-
lets. These PPE should include N95 masks, face protec-
tion by face shield or at least goggles (Figure 1). There

Figure 1. Delivery room management (Figure copyright Dr Venkat Reddy Kallem).
should be facility for safe disposal of the PPE at the
exit of the room [24].
Mode of delivery in a suspected or confirmed
COVID positive pregnant women should be guided by
her obstetric assessment, and COVID 19 itself is not an
indication for induction of labor and operative delivery
[24,25].
Ideally, neonatal resuscitation should be done in a
separate room adjacent to the delivery room or oper-
ation theater which is designated for this purpose. In
situations where this is not feasible, the resuscitation
corner should be at least 2 m away from the delivery
table or a curtain can be used to physically separate
these areas [24]. The health personnel attending the
delivery should wear a full set of PPEs including N95
masks. Until further evidence, skin to skin contact
immediately after the birth should be avoided and
umbilical cord should be clamped immediately.
Resuscitation should follow standard NRP guidelines
and in case of any positive pressure ventilation
requirement, self-inflating bag with mask should be
preferred to T-piece resuscitator [24].
Postnatal management of a stable neonate
born to a suspected COVID 19 positive mother
Mother and the newborn should be kept together in a
designated isolation room. A caretaker who is not
COVID positive and not a contact should be allowed
in the room to take care of the baby (Figure 2).
Mother should be explained to use surgical mask and
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3
maintain respiratory hygiene while caring the baby.
During the time when mother is not giving direct
care, at least 2 m distance should be maintained
between mother and the baby [24]. Mother can breast
feed her baby after proper hand and breast hygiene
[24–26]. Newborn should be monitored regularly for
vitals and routine examination by health care person-
nel with adequate PPE . Routine blood tests and
swabs for COVID are not recommended. If the moth-
er’s swabs are positive for COVID, then swabs from
neonate should be collected as per protocol [27].
Newborn can be discharged along with mother and
birth vaccination should be completed prior to dis-
charge [27].
Postnatal management of a stable neonate
born to a confirmed COVID 19
positive mother
If the resources for isolation of normal, suspected and
confirmed COVID positive mothers are not available,
neonate can be roomed in with mother (Figure 3).
Mother–infant dyad should be isolated from other sus-
pected/confirmed cases [24]. Mother can breastfeed
her baby after proper hand and breast hygiene. If the
facilities for isolation are available, immediately after
delivery neonate should be isolated from mother
(Figure 4). Health care taker who is not COVID positive
or a contact should be allowed to take care of the
baby. Mother can express milk after proper hand
hygiene while wearing a surgical mask [24]. This milk
4 V. R. KALLEM AND D. SHARMA

Figure 2. Postnatal management of a stable neonate born to a suspected COVID mother (Figure copyright Dr Venkat
Reddy Kallem).

Figure 3. Postnatal management of a stable neonate born to a confirmed COVID mother with facilities for separate isolation not
available (Figure copyright Dr Venkat Reddy Kallem).

can be given to the baby with a spoon or a paladai. A
dedicated breast pump can be used for expression of
milk. Baby can be shifted to mother and breast feed-
ing needs to be resumed once mother becomes
asymptomatic and mother’s swabs are negative twice
at least 24 h apart. Newborn should be monitored
regularly for vitals and routine examination by health
care personnel with adequate PPE. Newborn should
be tested at 24 h of life and if this sample is negative,
repeat the test again after 48 h. If the neonate’s RT-
PCR is positive and baby is symptomatic baby, it
should be shifted to separate designated ICU; if the
baby is stable, shift to mother and continue monitor-
ing. If the neonate’s RT-PCR is negative and baby is

Figure 4. Postnatal management of a stable neonate born to a confirmed COVID mother with facilities for separate isolation avail-
able (Figure copyright Dr Venkat Reddy Kallem).
separated from mother, baby can be discharged with
care taker until mother recovers. If the neonate’s RT-
PCR is negative and the baby is with mother, baby
can be with mother and droplet precautions to
be taken.
Postnatal management of a sick neonate born
to a suspected/confirmed COVID 19
positive mother
Neonate should be transported preferably in a closed
incubator by transport team after wearing adequate
PPE (Figure 5) [27]. Ideally, it should be managed in a
separate isolation facility; if facilities are not available,
the suspected and confirmed cases should be separated
by some distance (Figure 6). These rooms should be
negative air-borne isolation rooms or this negative
pressure can also be created by using 2–4 exhaust fans
which can drive air out of the room [24]. Adequate ven-
tilation of these rooms should be ensured with at least
12 air changes/hour. Health care personnel involved in
the care of these babies should be dedicated to them
only and should not involve in the care of the other
babies. The samples should be collected from the
symptomatic neonates as soon as possible and if nega-
tive, they should be repeated after 48 h. Confirmed
cases should be managed preferably in closed incuba-
tors and all the supportive care (fluids, inotropes and
empirical antibiotics) should be as per unit protocol.
Respiratory support in the form of NIPPV and HHHFNC
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 5
should be avoided in view of aerosol generation.
Though CPAP support also has the potential of aerosol
generation as it has many benefits, especially in pre-
term neonates CPAP can be used with lowest possible
flows. Expressed breast milk can be given using a pala-
dai or spoon if the baby is stable and via orogastric
tube if the baby is not able to take orally. Specific drugs
in the form of chloroquine/hydroxy chloroquine and
adjunctive therapy in the form of systemic steroids/
intravenous immunoglobulins are not recommended in
neonatal management till further evidence.
These neonates can be discharged if the following
requirements are met: (1) temperature returns to nor-
mal for more than 3 days; (2) respiratory symptoms
and chest radiography improved dramatically; (3)
nasopharyngeal and pharyngeal swabs, show negative
for COVID 19 for two consecutive times (with at least
a 24-h interval) [28]. We have proposed flow chart of
the delivery room management and post-natal man-
agement of neonate born to COVID 19 suspected
mother (Figure 7).
Prevention
Since there is no approved treatment or drug for this
disease, prevention of infection and breaking the
chain of transmission plays a crucial role. Challenges
for effective implementation of preventive measures
are infectivity before the onset of symptoms, nonspe-
cific symptoms, long incubation period, tropism for
6 V. R. KALLEM AND D. SHARMA

Figure 5. Transport of the neonate (Figure copyright Dr Venkat Reddy Kallem).

mucosal surfaces, prolonged duration of illness and 3. Maintaining respiratory hygiene and

Figure 6. Postnatal management of a sick neonate born to a suspected/confirmed COVID mother (Figure copyright Dr Venkat
Reddy Kallem).

potential for transmission even after recovering cough etiquette

from symptoms.
Important steps in prevention of infection are:
1. Isolation of suspected/confirmed cases from gen-
eral population in home/designated hospitals
2. Maintaining social distance (at least 2 m)
4. Strict usage of PPE for health care personnel who
are involved in the care of these infected people
5. Adequate hand hygiene (frequent hand washing
and using alcohol-based hand rubs, following
WHO five moments of hand hygiene)
6. Proper cleaning and disinfection of the surfaces
 THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 7

Figure 7. Flow chart of the delivery room management and post-natal management of neonate born to COVID 19 suspected
mother (Figure copyright Dr Venkat Reddy Kallem).
8 V. R. KALLEM AND D. SHARMA
a. Cleaning with soap and water or detergent
b. Application of disinfectant after cleaning
c. For disinfection of large surfaces 0.5% sodium
hypochlorite (5000 ppm) can be used
d. For small surfaces in between the two usages
and for small equipment (stethoscope) 70%
ethyl alcohol can be used
e. For surface cleaning of incubators, radiant
warmers, syringe pumps, weighing scales and
phototherapy machines 0.1% Hydrogen per-
oxide can be used (should be used when the
machinery is not in use)
7. Vaccine for the virus is under trials and may fol-
low near future
Conclusion
The current outbreak of Corona virus disease 2019 has
become the most serious public health emergency.
Though majority of the cases are seen in adult popula-
tion, children and newborns are not entirely exempted
from the epidemic. Evidence available is updating day
by day so emphasis should be on increasing aware-
ness among the people and health care personnel,
infection control measures and supportive care.
Disclosure statement
No potential conflict of interest was reported by
the author(s).
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