What do we know about COVID-19 and newborns?

**April 3, 2020 Update!

This post is now almost a month old. We now have compelling evidence that COVID-19 can likely be passed from mom the baby during pregnancy as well as a case of a newborn in CT dying from the virus. I am working on an updated post which will include the most recent guidelines for how to manage COVID-19 mothers and babies. In the meantime I can be reached with questions at primrosenewborncare@gmail.com.

What do we know about coronavirus (COVID-19) and newborns?

The short answer is, unfortunately, not very much.

Here is overview of that we do know as of March 15, 2020 (updated from original post on March 7, 2020):

**There are several reports in the media on 3/14/2020 that a newborn tested positive in London within moments of being born to a mother with COVID-19. It is unclear if this baby contracted the virus in utero or during delivery, or if the baby's test is actually reflecting maternal colonization. We can see this (viral testing reflecting mother's infection, not baby's) happen with other viruses, like herpes simplex virus (HSV), thus we do not test surface swabs of babies exposed to maternal HSV until they are at least 24 hours old. I will update this post in regards to this case once I am able to get medical information from sources that I trust more than mainstream media sources**

Pregnancy:

We do know that physiologic and immune system changes during pregnancy cause women to be at a higher risk of getting sick from viral illnesses. For example, pregnant women are at a higher risk of getting influenza-related pneumonia than those who are non-pregnant. Although there is one study from China showing that pregnant women who get coronavirus do not seem to be at high risk from viral complications, there are not enough women in the study to draw conclusions in regards to this.

There have been no confirmed cases of transmission of coronavirus from mom to baby during pregnancy or labor and delivery (vertical transmission). In one recently published Chinese study in the Lancet, 9 COVID-19 positive pregnant women who delivered by c-section gave birth to healthy newborns (none of the babies got the virus). These results have been widely circulated in the media over the last few weeks. We also know that, as of yet, umbilical cord blood, amniotic fluid, and breastmilk samples that have been tested for COVID-19 have all been negative.

Obstetricians are recommending that all pregnant women continue to get routine prenatal care and that they call their offices for testing if they have any concerns that they have been exposed to COVID-19 and/or might have it. In addition, any pregnant woman with fever, cough, and difficulty breathing should be seen as soon as possible. As of the week of March 9, 2020 testing for COVID-19 is finally supposed to be available in all 50 states.

It’s important for pregnant women with coronavirus to plan for a hospital birth due to the risk of themselves developing complications from the virus (i.e. pneumonia) and also so that their newborns can be closely monitored for the development of viral symptoms (as there is not much info in regards to what to expect with infections in newborns, see below).

Newborns:

Thus far there have only been 3 published cases of newborns (babies ≤ 28 days) in the medical literature testing positive for COVID-19 after birth. All three babies live in China and had family members/close contacts who were sick with coronavirus. Here is what we know about the 3 babies:

1. Baby #1: Did not have any symptoms but had a positive test when he was 30-36 hours old. His mom had symptoms and tested positive. Although it's believed he was exposed to COVID after birth, transmission during labor and delivery has not been ruled out.

2. Baby #2 had sick family members, developed a fever on day of life 5 and his test was positive for the virus. He had no other symptoms and did well.

3. Baby #3 had sick contacts and became symptomatic on day of life 17. Her symptoms included fever, difficulty breathing, vomiting, and mildly elevated cardiac enzymes.

From what I can find online these three full-term, COVID-19 positive newborns were closely monitored and recovered.

There is a recent care series of 10 Chinese newborns born to mothers with COVID-19 that is a bit concerning and has not yet made its way into the mainstream media. In a recently published clinical analysis of these ten babies 6 developed shortness of breath, 2 had fever, 2 had abnormal platelets and liver function tests, and 1 had vomiting. One of the babies developed a septic-shock clinical picture and died, 5 recovered, and at the time of publication 4 were still in the hospital. All 10 of these babies tested negative for COVID-19 (thus were not considered to be positive cases), and there is not any follow-up information available at the present time.

If a newborn develops any of the following symptoms they should be evaluated by a medical professional as soon as possible. All of these symptoms can be from any infectious illness, not just COVID-19.

• Fever (greater than or equal to 100.4F)

• Cough

• Difficulty breathing or quick breathing

• Lethargy

• Refusing to eat

• Vomiting

Older Infants:

There was an article in JAMA last month detailing the clinical course of 9 infants in China who tested positive for COVID-19 between 1-12 months of age. All of these babies were exposed to coronavirus at home. Of the nine babies 4 had fever, 2 had upper respiratory symptoms, 1 had no symptoms, and there is no information available on the last two. The authors of this paper recommend that parents with COVID-19 protect their infants by wearing masks, thorough hand washing before all contact, and making sure to sterilize baby toys, tableware, etc. on a regular basis.

Breastfeeding:

There have not been any case reports of COVID-19 being passed from mother to baby via breastfeeding. We also know that for most infections that it’s recommended that infected mothers continue to breastfeed their newborns as they are able to pass helpful antibodies and other immune proteins to their babies through milk.

The CDC recommends that mothers with confirmed or suspected coronavirus continue to provide breast milk to their newborns, but should take the following precautions to prevent spreading the virus:

1. Careful hand washing before touching her newborn.

2. Wear a face mask, if possible, while feeding at the breast.

3. Making sure to wash hands before breast pumping and carefully clean pump and pump parts after every pumping session.

4. If your baby is getting pumped milk, a well, not infected family member should be the one to bottle feed, if possible.

Similar precautions should also be taken for COVID-19 positive/suspected mothers who are formula feeding or combination feeding.

Premature Babies:

We do not have any information in this regard, other than that there is limited information from China that moms with COVID-19 seem to be at a higher risk of going into preterm labor. There have not been any published case reports of preemies who have tested positive for coronavirus. However, we do know that preemies are at a much higher risk of getting very ill from other community-acquired viruses, like RSV, so it’s hard to imagine that the risk of COVID-19 to preemies is any different.

It’s essential that premature babies be kept away from any one with a fever, cough, or possible illness. As it appears that COVID-19 positive patients may shed the virus for weeks, I recommend that preemies have no visitors who have had confirmed or suspected coronavirus in the last two months (outside of parents and direct caregivers). In addition, preemies should be kept away from anyone with a known COVID-19 exposure until it’s certain that they have not came down with the virus for at least 2 weeks after exposure.

I will continue to update this post as we get more information on the risks of COVID-19 in the preterm population.

How to Keep Your Newborn Baby Safe:

I recommended all of the following in a recent interview:

1. Wash your hands or use hand sanitizer every time you touch your baby.

2. Limit visitors in the first few weeks after giving birth and make sure that people who have recently been sick and/or possibly exposed to COVID-19 do not visit. Visitors wearing masks will not be enough to protect a newborn from this virus.

3. Breastfeed, if possible, to help bolster your baby’s immunity. Even partial breast milk will make a big difference in helping your baby to fight off infection!

4. If you are pumping breast milk, make sure to clean and disinfect your pump and all parts before and after every use.

5. Call your baby’s doctor if you have any concerns about his or her symptoms, including a fever, quick breathing, cough, and/or refusing to eat.

Resources:

Academy of Breastfeeding Medicine. Coronavirus Treatment and Risk to Breastfeeding Women. Published online March 4, 2020.

American College of Obstetricians and Gynecologists (ACOG) Practice Advisory: Novel Coronavirus 2019 (COVID-19).

CDC.gov. COVID-19 Update - Information for Clinicians and Pregnant Women. Webinar recorded and published on March 12, 2020.

CDC.gov. Interim Guidance on Breastfeeding for a Mother Confirmed or Under Investigation for COVID-19. Published online February 19, 2020.

The Lancet. What are the risks of COVID-19 infection in pregnant women? Published online February 12, 2020.

New York Times Parenting. Pregnant and Worried about Coronavirus? Experts Weigh In. Published online March 6, 2020.