Editorial
Neonatal COVID-19: little evidence and the need for more information
COVID-19 neonatal: poucas evidências e necessidade de mais informações
Renato Soibelmann Procianoya,b,
, Rita C. Silveiraa, Paolo Manzonic, Guilherme Sant’Annad
Corresponding author
a Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
b Chief Editor of the Jornal de Pediatria, Porto Alegre, RS, Brazil
c Hospital Universitário Degli Infermi, Department of Maternal-Infant Medicine, Ponderano, Italy
d McGill University Health Center, Montreal, Canada
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Silveira, Paolo Manzoni, Guilherme Sant’Anna" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Renato Soibelmann" "apellidos" => "Procianoy" "email" => array:1 [ 0 => "rprocianoy@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rita C." "apellidos" => "Silveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Paolo" "apellidos" => "Manzoni" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Guilherme" "apellidos" => "Sant’Anna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Chief Editor of the Jornal de Pediatria, Porto Alegre, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Universitário Degli Infermi, Department of Maternal-Infant Medicine, Ponderano, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "McGill University Health Center, Montreal, Canada" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "COVID-19 neonatal: poucas evidências e necessidade de mais informações" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Based on available reports (up to the writing of this editorial) and on scientific data reported by China, Italy, and the United States, newborn infants appear to be significantly less affected by COVID-19 than adults.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1–3</span></a> However, the lack of high-quality evidence for this situation and the steadfast pace of new and conflicting information has been an overall challenge to all medical specialties, including neonatal intensive care. In reality, the current knowledge on neonatal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is limited. Therefore, several questions remain unanswered, while at the same time the neonatal community needs to take action. Not surprisingly, this has caused significant stress amongst neonatal health care providers.</p><p id="par0010" class="elsevierStylePara elsevierViewall">All over the world, a number of important groups have been diligently working on the development of protocols and guidelines for the neonatal COVID-19 outbreak.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">4–7</span></a> In Brazil, a significant number of documents on this subject have been rapidly produced by national entities such as the Brazilian Society of Pediatrics, the Ministry of Health, and the Neonatal Resuscitation Program.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8–11</span></a> Undoubtedly, these are critical and paramount steps in the fight against the outbreak, but given the constant updating and some conflicting information, health care providers are facing difficulties in determining best local guidelines. To make things even more challenging, daily (and often non-scientific) news is released by the press.</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What's known about neonatal COVID-19 infection?</span> It is not yet established whether COVID-19 has transplacental or vertical transmission. Recently, a report from China described three infants with elevated serum levels of IgG and IgM antibodies for SARS-CoV-2 after birth.<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">12,13</span></a> The postnatal courses were benign and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) from nasopharyngeal swabs, serum, vaginal secretions, and maternal breast milk were negative. Thus, in the light of negative RT-PCR results and given that IgM false positives results are not uncommon, and that the decline of IGM levels were very unusual in comparison with other congenital infections, the possibility of maternal-infant transmission is difficult to ascertain.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> Fetal outcomes may depend more on the severity of the maternal infection and/or concomitant obstetric diseases, rather than on a putative transmission of the COVID-19 from the pregnant mother to the fetus.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> At this point, very few positive confirmed neonatal COVID-19 cases have been reported in scientific journals, and all of them had no symptoms or very mild to moderate symptoms, with no fatal cases reported in infants <28 days.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1–3,16–19</span></a> Acquisition of COVID-19 has been so far attributed to horizontal transmission from an infected mother or health care provider, rather than vertical. Based on this limited evidence, no specific clinical picture for neonatal COVID-19 infection has consistently emerged. Indeed, a few positive cases of neonatal COVID-19 in Brazil have been very recently reported by the news or personal communications, and clinical presentations and neonatal courses were reassuringly similar to the reported cases. Nevertheless, as the disease continues to spread throughout the world, we must remain vigilant.</p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What should neonatal health care providers do about COVID-19?</span> First, all aspects involved in neonatal care (intensive or not) must be re-evaluated in the context of the pandemic. Normal newborn nurseries, neonatal units of intermediate-level care, and neonatal intensive care units (NICUs) must be prepared and adopt practices that follow the best available evidence for the outbreak. This effort involves guidelines for the following: organization of unit space and/or isolation rooms or special areas for suspected or confirmed cases, policies for visitation by parents and family, and adoption of personal protective equipment (PPE) during delivery of a suspected or positive COVID-19 mother or during neonatal care. Moreover, clear guidelines are needed for all types of procedures in the delivery room or during the hospital stay, such as cord clamping, cleaning of secretions, suction of airways and stomach, use of all the different types of respiratory support, breastfeeding, operational protocols for in-hospital transport (to radiology or operating rooms), transport of outborn neonates, and selection/scheduling of cases that should be tested.</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What should be done for the overall care after birth?</span> Clinical conditions of mother and newborn will determine the care after birth. If the mother has suspected or confirmed COVID-19, both are stable, and the infant is not preterm, neonatal health care providers must offer orientations regarding precautions to avoid spreading the virus, including washing of the mother's hands before touching the infant, using a face mask while breastfeeding, and staying in isolated rooming-in. However, if the mother or the newborn are sick they should stay separated, while considering the mother's intention to breastfeed by expressing breast milk, limiting visits, and maintaining adequate isolation measures during the hospital stay.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> Neonates positive for COVID-19 must be isolated and clinically monitored, in order to prevent outbreaks in the NICU. Owing to the absence of evidence for vertical transmission, as well as for transmission through breast milk, most scientific organizations are recommending not to separate mothers and neonates, with the aim of promoting breastfeeding and neonatal bonding, with the exception of cases with severely symptomatic mothers – in such cases, barrier measures are suggested, as well as administration of expressed maternal milk.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">What to do when neonatal respiratory care is needed?</span> Important questions related to respiratory management during the immediate postpartum period of infants born from suspected or positive COVID-19 mothers, and the necessary protection that health care providers should use, have been addressed.<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> Also, questions have been raised about what forms of respiratory support can be safely used in the NICU in infants admitted with suspected or confirmed COVID-19, or who became positive during hospitalization.</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Can we continue to use current respiratory strategies?</span> Yes, with a few suggested modifications to address the possibility of aerosol generation and exhaled air dispersion during oxygen administration and ventilatory support.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">23,24</span></a> Of note, a systematic review published in 2014 by the World Health Organization (WHO) graded the evidence for using precautions against aerosol generation and exhaled air dispersion as <span class="elsevierStyleBold">very low</span>, with no studies evaluating neonates.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> Based on engineering data using adult models, the likelihood of significant aerosol generation and air dispersion during bag and mask ventilation, continuous positive airway pressure, nasal intermittent positive pressure ventilation, high flow nasal cannula therapy, endotracheal intubation, and invasive mechanical ventilation is quite low, but not negligible.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26–28</span></a> Given the lack of strong and clear scientific evidence during this pandemic, and until more information becomes available, health care providers should use full PPE during respiratory care of infants with suspected or confirmed cases. This should include gloves, a long-sleeved gown, eye protection, and a N95 mask or the equivalent. Also, it is recommended that infants with suspected or positive COVID-19 infection should be treated in negative pressure rooms or isolated using a 2-m distance between incubators in open plan NICUs.</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Two final points deserve special attention: immediate endotracheal intubation and use of bacterial/viral filters</span>. There is no evidence that neonates need to be immediately intubated in case of respiratory deterioration solely because of COVID-19 infection. First, because the pathophysiology of the disease is different, no cases of neonatal SARS-CoV-2 infection have been documented. Second, mechanical ventilation-associated lung injury is clearly an issue when dealing with neonatal lungs.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> Third, data coming from adults suggests that endotracheal intubation is the major aerosol generating procedure and should not be performed prophylactically.<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">23,24</span></a> Fourth, during previous viral epidemics a number of adults were successfully treated with non-invasive respiratory support without any evidence of increased contamination or aerosol dispersion.<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> Thus, the only recommended modification for contemporary respiratory care is the use of bacterial/viral hydrophobic filters located at the expiratory part of the systems. Any strategy in such neonates should be tailored to the individual patient, rather than to the disease. This has already been clearly outlined by the Brazilian Pediatric Society and the national Neonatal Resuscitation Program.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8,9</span></a> It is important to highlight that the addition of a filter, although effective in decreasing viral dispersion, adds dead space and increases system resistance, which could be harmful to preterm infants if left in place for long periods. Therefore, when using these filters, health care providers should be mindful of the potential complications and monitor the infants closely. Also, in infants receiving bubble continuous positive airway pressure (CPAP), filters may also increase system resistance, and spot checks of the pressure can guarantee safe application.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This editorial reflects the current knowledge on neonatal COVID-19, but as the outbreak and information are changing rapidly, continuing to watch for updates is highly recommended.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Procianoy RS, Silveira RC, Manzoni P, Sant’Anna G. Neonatal COVID-19: little evidence and the need for more information. J Pediatr (Rio J). 2020;96:269–72.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "Y. Dong" 1 => "X. Mo" 2 => "Y. Hu" 3 => "X. Qi" 4 => "F. Jiang" 5 => "Z. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 4 | 14 |
| 2024 October | 24 | 18 | 42 |
| 2024 September | 38 | 20 | 58 |
| 2024 August | 52 | 34 | 86 |
| 2024 July | 63 | 41 | 104 |
| 2024 June | 43 | 14 | 57 |
| 2024 May | 36 | 16 | 52 |
| 2024 April | 44 | 38 | 82 |
| 2024 March | 30 | 22 | 52 |
| 2024 February | 28 | 23 | 51 |
| 2024 January | 31 | 26 | 57 |
| 2023 December | 18 | 24 | 42 |
| 2023 November | 41 | 33 | 74 |
| 2023 October | 34 | 37 | 71 |
| 2023 September | 30 | 43 | 73 |
| 2023 August | 26 | 19 | 45 |
| 2023 July | 38 | 15 | 53 |
| 2023 June | 20 | 9 | 29 |
| 2023 May | 33 | 15 | 48 |
| 2023 April | 21 | 17 | 38 |
| 2023 March | 48 | 14 | 62 |
| 2023 February | 38 | 19 | 57 |
| 2023 January | 35 | 17 | 52 |
| 2022 December | 61 | 32 | 93 |
| 2022 November | 45 | 27 | 72 |
| 2022 October | 66 | 41 | 107 |
| 2022 September | 52 | 34 | 86 |
| 2022 August | 48 | 42 | 90 |
| 2022 July | 66 | 44 | 110 |
| 2022 June | 44 | 44 | 88 |
| 2022 May | 57 | 38 | 95 |
| 2022 April | 96 | 54 | 150 |
| 2022 March | 90 | 52 | 142 |
| 2022 February | 63 | 33 | 96 |
| 2022 January | 48 | 39 | 87 |
| 2021 December | 38 | 23 | 61 |
| 2021 November | 24 | 18 | 42 |
| 2021 October | 26 | 25 | 51 |
| 2021 September | 22 | 16 | 38 |
| 2021 August | 41 | 18 | 59 |
| 2021 July | 34 | 15 | 49 |
| 2021 June | 53 | 18 | 71 |
| 2021 May | 62 | 27 | 89 |
| 2021 April | 156 | 86 | 242 |
| 2021 March | 147 | 59 | 206 |
| 2021 February | 71 | 40 | 111 |
| 2021 January | 40 | 23 | 63 |
| 2020 December | 42 | 31 | 73 |
| 2020 November | 43 | 29 | 72 |
| 2020 October | 29 | 16 | 45 |
| 2020 September | 49 | 19 | 68 |
| 2020 August | 93 | 25 | 118 |
| 2020 July | 151 | 47 | 198 |
| 2020 June | 123 | 45 | 168 |
| 2020 May | 106 | 52 | 158 |
| 2020 April | 52 | 37 | 89 |
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