June 15, 2021


Zeng L, Xia S, Yuan W, et al. Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr. 2020;174(7):722–725. doi:10.1001/jamapediatrics.2020.0878. PMID: 32215598


Varsha Rao FRACP
Consultant Paediatrician
Mater Misericordiae Hospital, Mackay
Queensland, Australia

Gopakumar Hariharan MD FRACP
Consultant Neonatologist
Senior lecturer, James Cook University
Mackay Base Hospital, Queensland Health




Outcome of neonates born to COVID positive mothers


  • Design: Prospective cohort study
  • Allocation: Not applicable
  • Blinding: Not applicable
  • Follow up period: Not applicable
  • Setting: This is a single Centre study that analysed all neonates born to mothers with COVID-19 at Wuhan Children’s Hospital from January 2020 to February 2020.
  • Patients: All neonates born to mothers with COVID-19 during the study period were included in the study.
  • Intervention: Not applicable
  • Outcomes:
    • Primary outcome: Early onset SARS-CoV-2 infection in neonates
    • Secondary outcomes: Morbidities in neonates with positive SARS-CoV-2
  • Analysis and sample size: 33 neonates born to mothers with COVID 19 were studied.
  • Patients follow up: Neonatal period (duration not specified)


Of the thirty-three neonates born to mothers with COVID-19, 3 neonates (9%) were positive for SARS-CoV-2. The most common symptom in neonates described in the study was shortness of breath and there was no case fatality.  Radiographic findings were non-specific.

All the 3 neonates who were SARS-CoV-2 positive were born by Caesarean Section. The most seriously unwell neonate was born premature requiring resuscitation, non-invasive mechanical ventilation, treatment with antibiotics, caffeine and had a longer duration of stay.

Variable Neonates with SARS-CoV-2, n (%)
No (n=30) Yes (n=3)
Male 16 (53) 3 (100)
Preterm 3 (10) 1 (33)
Small for gestational age 2 (7) 1 (33)
Symptoms and complications
Fever 0 (0) 2 (67)
Pneumonia 0 (0) 3 (100)
Laboratory test (median range)
White cell count, cells/µL 9800 (6100-22700) 19200 (8600-20400)
Lymphocyte count, cells/µL 4300 (1500-10700) 2600 (800-3100)
Platelets, × 103/µL 184 (116-303) 245 (230-265)
Mechanical ventilation 0 (0) 1* (33)


Antibiotic 6 (20) 1 (33)
Duration of neonatal intensive unit, median (range), d 0 (0-6) 4 (2-11)
Death 0 0
Maternal features
Fever on admission 7 (23) 1 (33)
Postpartum fever 4 (13) 1 (33)
Pneumonia per computed tomography diagnosis 30 (100) 3 (100)
Nasopharyngeal swab 30 (100) 3 (100)
Delivered by Cesarean delivery 23 (77) 3 (100)
Premature rupture of membranes 2 (7) 1 (33)

Table1. Demographics, gestational age and clinical features of newborns born to mothers with COVID-19

*non-invasive mechanical ventilation for the 31-week preterm baby


The risk of SARS-CoV-2 infection in neonates exposed to COVID-19 positive mothers was low. Neonates with early onset-COVID had mild symptoms and a favourable outcome. The possibility of vertical transmission of COVID-19 was raised which requires further research.


The global pandemic caused by Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has affected a substantial number of pregnant women.(1) Although neonates have been reported to be positive for the virus infection, there is paucity of data on outcome and mode of transmission.

The predominant mode of transmission of SARS-CoV-2 is aerosol or direct contact.(2, 3)Evidence suggests that respiratory viruses are not commonly transmitted in-utero. Although vertical transmission has been postulated as a mode of transmission in early onset SARS-CoV-2 infection in neonates, there is no conclusive evidence to support this due to limitations related to sensitivity and specificity of diagnostic testing, variation in timing of tests for the virus and appropriate sample to determine infection conclusively.(4) Furthermore, there is lack of consensus regarding definition of vertical transmission.(4)

The study by Zeng et al was undertaken during the initial phases of the COVID-19 outbreak when there was limited information on neonatal infection. This study provided important information on the possibility of COVID infection in neonates. They described 3 neonates who were possibly infected. All the 3 neonates were born by Caesarean section and were tested on day 2 of life making it difficult to differentiate congenital infection from postnatal infection. The details of infection control precautions and feeding practices were not provided, and therefore unable to compare with the standards of care recommended. The possibility of vertical transmission was postulated based on PCR testing on nasopharyngeal and anal swabs, but the test does not differentiate between infection and superficial contamination.(4, 5) The reported clinical manifestations in the neonates were also confounded by pathologies seen in normal neonates, hence doesn’t categorically prove vertical transmission and COVID-19 as the cause for the symptoms. The outcome of neonates in this study was favourable, a finding that has not changed over the course of the ongoing pandemic.

Conflicting guidelines in managing neonates born to SARS COV2 infected mothers existed during the initial phases of pandemic in terms of rooming-in and breastfeeding practice across the world. Currently, the WHO recommendation is to encourage rooming-in, breastfeeding along with strict infection control precautions.

New mutant strains with differing virulence have evolved since the onset of the pandemic and further research will need to be undertaken to evaluate impact of these variants. Although data on neonatal COVID continues to emerge, there is paucity of evidence on mode of transmission. International multicentre collaborative studies using standardised testing that comprehensively evaluate the time of maternal infection during pregnancy (to differentiate in-utero vs intrapartum/postnatal neonatal infection), evaluate in-utero/intrapartum exposure (antibodies, amniotic fluid, placental tissue, cord blood) and postnatal exposure (serial antibody testing, serial nasopharyngeal PCR tests, cord blood, neonatal serum, breast milk) would be useful to determine vertical transmission of SARS-CoV-2 to neonates.


  1. World Health Organization (2021) Novel Coronavirus (2019-nCoV) situation reports (online) 2021 [Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports.
  2. Schwartz DA. An Analysis of 38 Pregnant Women With COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes. Archives of Pathology & Laboratory Medicine. 2020;144(7):799-805.
  3. Papapanou M, Papaioannou M, Petta A, Routsi E, Farmaki M, Vlahos N, et al. Maternal and Neonatal Characteristics and Outcomes of COVID-19 in Pregnancy: An Overview of Systematic Reviews. International journal of environmental research and public health. 2021;18(2).
  4. Organization WH. Definition and categorization of the timing of mother-to-child transmission of SARS-CoV-2: scientific brief, 8 February 2021. World Health Organization; 2021.
  5. Schwartz DA, De Luca D. The Public Health and Clinical Importance of Accurate Neonatal Testing for COVID-19. Pediatrics. 2021;147(2).

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