In December 2019, a new strain of coronavirus [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] causing a new disease [Coronavirus Disease 2019 (COVID-19)] was discovered in Wuhan, Hubei province, China. Since then, its rapid spread across the world has been declared a pandemic.1 As of April 17, 2020 there were 2,074,529 COVID-19 cases reported globally, with 139,378 deaths.2 Among SARS-CoV-2-infected children, about 12%–18% occurred in infants less than 12 months old.3–5 With relatively few reports of COVID-19 in neonates and infants, we present a small case series here.
A total of 70 infants were tested for SARS-CoV-2 between March 10, 2020 and April 17, 2020. Indication for SARS-CoV-2 investigation was generally guided by Public Health of England case definition and recommendation for testing:
- requiring admission to hospital, and
- have either clinical or radiologic evidence of pneumonia, acute respiratory distress syndrome or influenza-like illness defined by the presence of fever ≥37.8°C and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough (with or without sputum), hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing.
The types of samples sent were nasopharyngeal aspirate, nasal and/or throat swab.
Table 1 summarizes 8/70 (11.4%) infants tested positive for SARS-CoV-2. Of these, 4/8 infants (50%) were treated for suspected sepsis with broad-spectrum antibiotics, 5/8 (63%) developed fever, 4/8 (50%) had respiratory symptoms and lower respiratory tract involvement, 2/8 (25%) had neutropenia and thrombocytosis. Only 1/8 (13%) required admission to the pediatric intensive care unit (PICU) due to severe COVID-19. All patients eventually recovered and were discharged home.
We would like to highlight patient 4 in our report. This new born baby was delivered prematurely at 34 weeks of gestation via emergency cesarean section following induction of labor, as her mother was diagnosed with COVID-19. She was still able to breast-feed her baby after delivery. Both mother and baby were discharged after delivery.
At day 5, the baby presented with a 1-day history of decreased feeding, lethargy and jaundice. On examination, she was found to be hypothermic (rectal temperature 33.3°C), and subsequently developed multiple apneic episodes with desaturations whilst still in the pediatric emergency department. She was quickly placed in an incubator for rewarming, and then onto continuous positive airway pressure ventilation with oxygen (fraction of inspired oxygen 30%). Empirical antibiotics (amoxicillin, cefotaxime and gentamicin) were commenced immediately before PICU transfer.
Full blood count and C-reactive protein results were normal. No growth was detected in the blood culture. Increased opacity throughout both lungs was already present on her admission CXR. An echocardiography performed to exclude congenital heart disease showed a small ASD.
In PICU, the baby continued with continuous positive airway pressure for another 3 days before stepping down to a high-flow humidified nasal cannula. She was weaned off all respiratory support the next day. She also had brief phototherapy session for jaundice. Antibiotics were stopped prior to transfer to a general pediatric ward, from where she was discharged on day 8 of admission, fully recovered.
Seasonal coronaviruses typically cause mild respiratory tract infections which are self-limiting in both adults and children. Despite limited evidence thus far, there is now a general consensus that children are relatively protected from severe COVID-19, in contrast to the elderly and adults with underlying chronic health conditions.1,6
Earlier studies from China, Europe and the USA have shown relatively few infections in children, with severe illness and mortality being rare.1,3–5,7 Such low numbers of reported SARS-CoV-2 infections in children may be due to the selective testing of only those children who are ill enough to present to hospital, which is the current practice in these countries. In other countries that have adopted mass community SARS-CoV-2 screening, such as South Korea, the majority of pediatric patients were only mildly affected.8
With the 8 cases presented here (the youngest being only 5 days old), the most common symptoms were fever, cough and coryza. Only one (patient 4) needed PICU admission for respiratory support—most likely due to a combination of prematurity and SARS-CoV-2 infection. Although diarrhea and vomiting have been reported,9 this was not observed in this series. Three of the children (patients 1, 4 and 5) were also co-infected with other seasonal respiratory viruses, though this did not consistently prolong their admission more than the other cases (Table 1). Not all cases had CXRs performed, and where they were, they showed only mild parenchymal changes. There is still no convincing evidence of intrauterine vertical transmission,10 and it is likely that the neonate (patient 4) acquired her SARS-CoV-2 infection postnatally.
The clinical presentations in this small case series of COVID-19 in neonates and infants ranged from asymptomatic to moderately severe, but all cases recovered relatively quickly and were asymptomatic by discharge.
1. Morand A, Fabre A, Minodier P, et al. COVID-19 virus and children: what do we know? Arch Pediatr. 2020;27:117–118.
2. World Health Organization. Coronavirus disease (COVID-19) outbreak situation. 2020. Available at: https://covid19.who.int/
. Accessed April 17, 2020.
3. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among children in China. Pediatrics. 2020;pii: e20200702.
4. CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children - United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:422–426.
5. Lu X, Zhang L, Du H, et al. SARS-CoV-2 infection in children. N Engl J Med. 2020;382:1663–1665.
6. Wu Z, McGoogan JM. Characteristics of and important lessons from the Coronavirus Disease 2019 (COVID-19) Outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323:1239–1242.
7. European Centre for Disease Prevention and Control. Rapid risk assessment: Coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – eighth update.8 April 2020. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-eighth-update-8-april-2020.pdf
. Accessed April 18, 2020.
8. Korean Society of Infectious Diseases, Korean Society of Pediatric Infectious Diseases, Korean Society of Epidemiology, Korean Society for Antimicrobial Therapy, Korean Society for Healthcare-associated Infection Control and Prevention, Korea Centers for Disease Control and Prevention. Report on the Epidemiological Features of Coronavirus Disease 2019 (COVID-19) Outbreak in the Republic of Korea from January 19 to March 2, 2020. J Korean Med Sci. 2020;35:e112.
9. She J, Liu L, Liu W. COVID-19 epidemic: Disease characteristics in children. J Med Virol. 2020;1–8. doi: 10.1002/jmv.25807. [Epub ahead of print]
10. Chen H, Guo J, Wang C, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395:809–815.