The repercussions of infection by the new coronavirus severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) in pregnant women and newborns are still not well known,
with little scientific evidence about their manifestation in the mother-child binomial.
Vertical transmission seems possible but has not been documented (1,2). Furthermore,
the virus has not been detected in human milk, enabling breastfeeding with protection
or the use of expressed milk from the mother (1-3).
Several studies (1,3-7) published to date suggest the possibility of vertical transmission
of SARS-CoV-2, but none of them have confirmed this. The virus was not found in amniotic
fluid, placenta, umbilical cord blood, and breast milk samples.
Existing data suggest that neonatal transmission of SARS-CoV-2 occurs mainly through
droplets from infected caregivers or through contact with contaminated biological
material. There are clinical case reports that describe late infection in newborns
of mothers infected with SARS-CoV-2. Most of these children presented with mild signs
and symptoms, but some developed sepsis and severe respiratory failure (8-10).
We present a case that is similar to most reports in the literature published until
now: the patient was a male infant of a 37-year-old mother, with a gestational age
of 39 5/7 weeks and no prenatal complications. He was born vaginally, with Apgar scores
of 8 and 9 (1st and 5th minute), weight 3.050g, length 51 cm, and head circumference
35 cm. The mother’s amniotic membranes had ruptured 11 hours before delivery.
The patient presented with early respiratory distress, which improved after receiving
inhaled oxygen in the first 12 hours of life. Blood was collected to examine for early
neonatal sepsis; the results of the examination were normal. Chest radiography showed
a left clavicle fracture without pulmonary involvement. The patient was discharged
home on the third day of life, on exclusive breastfeeding. His family members complied
with the isolation requirements recommended by the Ministry of Health of Brazil (7),
and they were asymptomatic. This newborn had had no contact with other patients who
had flu-like syndrome.
At 11 days of age, the newborn had two episodes of hyperthermia and mild respiratory
distress, according to the mother's report. On examination, the blood count, blood
culture results, serum C-reactive protein levels, liquor levels, and type 1 urine
examination results were normal. Chest radiography did not reveal any changes in the
lung fields. Assessment of nasal and oropharyngeal samples for SARS-CoV-2 by reverse
transcription followed by polymerase chain reaction (RT-PCR) revealed positive results.
At age 13 days, the infant was transferred to the Neonatal Center of Instituto da
Criança, Hospital das Clínicas, Faculty of Medicine-University of São Paulo, and did
not show any respiratory symptoms in room air. He remained in room air throughout
hospitalization. He had a hemoglobin saturation greater than 94%, was afebrile, and
had a normal heart rate. Pulmonary ultrasonography showed changes compatible with
bilateral interstitial involvement (Figure 1). He was mostly breastfed, and was given
formula only when breast milk was unavailable.
The spectrum of clinical manifestations of SARS-CoV-2 infection in newborns is still
under study. Until now, the presence of the virus in biological materials has not
been sufficient to prove its vertical transmission (1,3,6). Case reports have indicated
postnatal acquisition of coronavirus disease (COVID-19), as in the case described.
The patient's mother did not present respiratory symptoms or show any other clinical
evidence of illness. The only finding was rupture of amniotic membranes 11 hours before
delivery. The newborn developed early and transient respiratory distress without other
complications. Respiratory distress in the neonatal period among neonates with COVID-19-positive
mothers may be related to the neonates innate conditions and should not always be
attributed to SARS-CoV-2 infection (1,3,8,9).
The patient remained in the exclusive breastfeeding room until discharge home on the
third day of life. The binomial was discharged home, where all residents followed
social isolation advocated by the state government and did not present any signs or
symptoms of COVID-19.
Horizontal transmission seems to be the most likely route of SARS-CoV-2 infection
in this case, perhaps through contact with an asymptomatic carrier of the virus.
In the studies (1,3,5,6) conducted until now, the human milk samples tested were negative
for the presence of the virus, which made it possible to continue breastfeeding even
in symptomatic women. In such cases, it is necessary that the rules of home isolation
be respected, suggesting participation of healthy family members in providing care
to the newborn during the period of maternal convalescence. The use of a surgical
mask, frequent hand hygiene, and observation for warning signs that the newborn may
present with are recommended.
The clinical manifestation of COVID-19 among children is characterized by fever, dry
cough, tiredness, and a runny nose. Some patients have manifestations in the digestive
tract, such as bloating, nausea, vomiting, diarrhea, and abdominal pain. Some cases
may present with skin rashes. The progression is generally benign, with complete resolution
of the condition within two weeks after symptom onset (11,12).
Descriptions of clinical manifestations in neonates are rarer. A case of severe late-onset
neonatal sepsis was recently reported at the University of Texas, with the newborn
needing orotracheal intubation and vasoactive drug administration (11).
Much attention is needed at this stage because, to date, the most severe respiratory
distress syndromes appear concomitantly with other conditions characteristic of the
neonatal period. One should always conduct assessments on a case-by-case basis, classify
respiratory failure, and prescribe the best treatment for the patient.
According to Hong et al., (12) the criteria for the diagnosis of COVID-19 among neonates
are as follows: thermal instability, hypoactivity, difficulty in feeding, or respiratory
distress; alterations of chest radiographs with a single or bilateral ground-glass
pattern; diagnosis of COVID-19 in a relative or caregiver of the newborn; and intimate
contact with people confirmed or suspected of having COVID-19 or with patients with
unexplained pneumonia.
Our patient fulfilled only two the criteria: temperature instability and mild respiratory
distress. His hemoglobin saturation at admission was 91% in room air. The tests collected
initially did not show any hematological changes, such as leukocytosis or leukopenia,
and the platelet count was normal. His serum C-reactive protein level was normal.
Because of the presence of fever, urine and cerebrospinal fluid samples were tested,
and meningitis and urinary tract infection were ruled out. Ampicillin, cefotaxime,
and oseltamivir were administered. The neonate tested positive for COVID-19 24 hours
after admission and was transferred to a Neonatal Intensive Care Unit for patients
with COVID-19 during the pandemic. The blood samples collected at hospital admission
did not show bacterial growth, and the administration of antibiotics was suspended
after 48 hours. The newborn was hospitalized for seven days. He remained asymptomatic
throughout the hospitalization, with oxygen saturation above 94% and a temperature
between 36.5 and 37°C. Disease progression was good, as in other cases (9,10) described
in the literature.
COVID-19 has a highly variable clinical presentation, and there are still few case
reports on COVID-19 in the neonatal period. Many neonates present with symptoms and
signs that overlap with those of diseases typical of this age range. The biggest challenge
is to recognize the characteristics of COVID-19 among other manifestations of neonatal
diseases and to choose the most appropriate treatment for the patients.