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Research Letter
March 26, 2020

Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China

Author Affiliations
  • 1Department of Neonatology, Institute of Maternal and Child Health, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  • 2Department of Neonatology, Maternal and Child Health Hospital of Hubei Province, Wuhan, China
  • 3National Children's Medical Center, Children’s Hospital of Fudan University, Shanghai, China
  • 4Institute of Maternal and Child Health, Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
JAMA Pediatr. 2020;174(7):722-725. doi:10.1001/jamapediatrics.2020.0878

The coronavirus disease 2019 (COVID-19) has spread rapidly across the world. With the sharp increase in the number of infections, the number of pregnant women and children with COVID-19 is also on the rise. However, only 19 neonates born to affected mothers have been investigated, and to our knowledge, no information on early-onset infection in newborns has been published in previous studies.1,2


In this cohort study, all neonates born to mothers with COVID-19 were recruited from Wuhan Children's Hospital, in Wuhan, Hubei Province, China. This study was approved by the local medical ethics committee. Written informed consent was obtained from the neonates’ parents. The diagnosis and management of newborns with or at risk of COVID-19 were in accordance with guidelines provided by the National Health Commission and the Chinese Perinatal-Neonatal SARS-CoV-2 Committee.3,4

Data regarding demographic, epidemiologic, and clinical features were obtained from the medical records system. In addition, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) real-time reverse transcriptase–polymerase chain reaction tests (Novel Coronavirus PCR Fluorescence Diagnostic Kit [BGI]) were conducted using nasopharyngeal and anal swab samples. Data were collected from January 2020 to February 2020. All statistical analyses were performed in Stata version 15.0 (StataCorp).


Thirty-three neonates born to mothers with COVID-19, including 3 neonates with COVID-19, were identified (Table). The most common symptom was shortness of breath (4 of 33 neonates). Radiographic findings were nonspecific. No deaths were reported.

Table.  General Information and Clinical Features of 33 Newborns With Mothers With COVID-19 Pneumonia
General Information and Clinical Features of 33 Newborns With Mothers With COVID-19 Pneumonia

We provide details of the 3 infected neonates (Figure). Patient 1 was born at 40 weeks’ gestation. The delivery was by cesarean delivery because of meconium-stained amniotic fluid and confirmed maternal COVID-19 pneumonia. On day 2 of life, the infant experienced lethargy and fever, with unremarkable physical examination results, and was moved to the neonatal intensive care unit. A chest radiographic image showed pneumonia, but other laboratory tests (except procalcitonin) were normal. Nasopharyngeal and anal swabs were positive for SARS-CoV-2 on days 2 and 4 of life and negative on day 6.

Figure.  Timeline and Imaging Findings of 3 Neonates Infected With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)
Timeline and Imaging Findings of 3 Neonates Infected With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)

Normal ranges: lymphocytes (L), 3000 to 8000 cells/μL (to convert to cells  × 109/L, multiply by 0.001); procalcitonin (PCT), <0.05 μg/L; white blood cell count (WBC), 8000-15000 cells/μL (to convert to cells × 109/L, multiply by 0.001). CBC indicates complete blood cell count; CT, computed tomography; NICU, neonatal intensive care unit; NIPPV, noninvasive positive-pressure ventilation; NRP, neonatal resuscitation program; RDS, respiratory distress syndrome; RT-PCR, reverse transcriptase–polymerase chain reaction.

Patient 2 was born at 40 weeks’ and 4 days’ gestation by cesarean delivery because of confirmed maternal COVID-19 pneumonia. He presented with lethargy, vomiting, and fever. A physical examination was unremarkable. Laboratory tests showed leukocytosis, lymphocytopenia, and an elevated creatine kinase–MB fraction. A chest radiographic image showed pneumonia. Nasopharyngeal and anal swabs were positive for SARS-CoV-2 on days 2 and 4 of life and negative on day 6.

Patient 3 was born at 31 weeks’ and 2 days’ gestation by cesarean delivery because of fetal distress and confirmed maternal COVID-19 pneumonia. Resuscitation was required. The infant’s Apgar scores were 3, 4, and 5 at 1, 5, and 10 minutes after birth. Neonatal respiratory distress syndrome and pneumonia confirmed by chest radiographic image on admission resolved on day 14 of life after treatment with noninvasive ventilation, caffeine, and antibiotics. He also had suspected sepsis, with an Enterobacter agglomerates–positive blood culture, leukocytosis, thrombocytopenia (11 cells × 103/μL; to convert to cells  ×  109/L, multiply by 1.0), and coagulopathy (prothrombin time, 21 seconds; activated partial thromboplastin time, 81.9 seconds), which improved with antibiotic treatment. Nasopharyngeal and anal swabs were positive for SARS-CoV-2 on days 2 and 4 of life and negative on day 7.


Consistent with previous studies, the clinical symptoms from 33 neonates with or at risk of COVID-19 were mild and outcomes were favorable.1,2,5 Of the 3 neonates with symptomatic COVID-19, the most seriously ill neonate may have been symptomatic from prematurity, asphyxia, and sepsis, rather than SARS-CoV-2 infection.

In this cohort, 3 of 33 infants (9%) presented with early-onset SARS-CoV-2 infection. Because strict infection control and prevention procedures were implemented during the delivery, it is likely that the sources of SARS-CoV-2 in the neonates’ upper respiratory tracts or anuses were maternal in origin. Although 2 recent studies1,2 have shown that there were no clinical findings or investigations suggestive of COVID-19 in neonates born to affected mothers, and all samples, including amniotic fluid, cord blood, and breast milk, were negative for SARS-CoV-2, the vertical maternal-fetal transmission cannot be ruled out in the current cohort. Therefore, it is crucial to screen pregnant women and implement strict infection control measures, quarantine of infected mothers, and close monitoring of neonates at risk of COVID-19.

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Article Information

Accepted for Publication: March 10, 2020.

Corresponding Author: Wenhao Zhou, MD, National Children's Medical Center, Children’s Hospital of Fudan University, 399 Wanyuan Rd, Shanghai 201102, China (zhouwenhao@fudan.edu.cn).

Published Online: March 26, 2020. doi:10.1001/jamapediatrics.2020.0878

Author Contributions: Dr Zeng had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Zeng, Shao, Zhou.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: Xia, Yuan, Xiao, Shao, Zhou.

Statistical analysis: Zeng, Yuan, Yan, Xiao.

Administrative, technical, or material support: Zeng, Xia, Yan, Shao, Zhou.

Supervision: Shao, Zhou.

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Shoo K. Lee, MD, Department of Obstetrics and Gynecology and Department of Public Health, University of Toronto, for editing assistance. He was compensated for his contribution. We thank the patients’ families for granting permission to publish this information.

Zhu  H, Wang  L, Fang  C,  et al.  Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia.   Transl Pediatr. 2020;9(1):51-60. doi:10.21037/tp.2020.02.06 PubMedGoogle ScholarCrossref
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(10226):809-815. doi:10.1016/S0140-6736(20)30360-3PubMedGoogle ScholarCrossref
National Health Commission of China. New coronavirus pneumonia prevention and control program (4th edition). Accessed March 9, 2020. http://www.gov.cn/zhengce/zhengceku/2020-01/28/5472673/files/0f96c10cc09d4d36a6f9a9f0b42d972b.pdf.
Wang  L, Shi  Y, Xiao  T,  et al; Working Committee on Perinatal and Neonatal Management for the Prevention and Control of the 2019 Novel Coronavirus Infection.  Chinese expert consensus on the perinatal and neonatal management for the prevention and control of the 2019 novel coronavirus infection (first edition).   Ann Transl Med. 2020;8(3):47. doi:10.21037/atm.2020.02.20PubMedGoogle ScholarCrossref
Wei  M, Yuan  J, Liu  Y, Fu  T, Yu  X, Zhang  ZJ.  Novel coronavirus infection in hospitalized infants under 1 year of age in China.   JAMA. 2020. doi:10.1001/jama.2020.2131PubMedGoogle Scholar
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    3 Comments for this article
    Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China
    Richard Banati, MD, PhD, Professor | University of Sydney, Medical Director of Mothers Milk Bank Charity
    Three of the 33 newborns tested positive for COVID-19. These 3 infants were delivered by caesarean section.

    In light of important policy decision to be made, it would be important to know whether the infants were separated from their mothers, whether breastfeeding was initiated or whether expressed or donor human milk was provided.

    Human milk contains components (free fatty acids and monoglycerides) with potent antiviral activity against enveloped viruses (SARS-CoV-2 being one such virus) but possibly also antibodies, either cross-reacting or specific if the mother had been infected with SARS-CoV-2 (1).

    Evidence from earlier epidemics indicates
    that the multiple disease risks associated infant formula feeding can be avoid through breastmilk feeding even or, case-dependent, especially in the presence of a higher pathogen exposure risk.


    1. https://www.biorxiv.org/content/10.1101/2020.03.11.987958v1
    What Was Treatment/intervention for Each Neonate, and Did They Breastfeed?
    MoCha Vaz, RN | Trinitas RMC
    It would be most informative to have included the exact treatment ( (eg, antibiotics, caffeine) and interventions provided to these sick neonates. Also, the length of time of recovery. The report also failed to include if the newborns received the mother's breast milk or were given formula. Although the article was very vague in some areas, it is most hopeful to know the newborns survived.
    Neonatal Early-Onset Infection With COVID-19
    Rajesh Dudani, MD | John H Stroger Hospital of Cook County
    The authors have presented 3 cases of possible vertical maternal-fetal transmission of COVID-19 infection but details about postnatal care was not given regarding breast feeding, separation from mother, isolation of the infants, and precautions taken by caregivers. Shortness of breath was mentioned as the most common symptom but only one patient had shortness of breath who was positive for COVID-19 and it seems most likely it was due to prematurity-related respiratory distress syndrome or sepsis. Two of the three patients positive for COVID-19 had fever. It may be important to rule out other infections and treat empirically for possible bacterial infection or herpes which may have serious consequences in a context of patients having fever and lethargy. All three patients were diagnosed with pneumonia on the basis of chest x-ray which is generally nonspecific in newborns for pneumonia. The two patients did not have any signs and symptoms of respiratory compromise like tachypnea, cough, respiratory distress or oxygen requirement. For patients 2 and 3, it was mentioned that patients had leukocytosis but it is within normal range for age. The authors have recommended close monitoring and appropriate precautions for these neonates at risk of COVID-19 which seems important as these newborns are at risk for early and late onset infection due to COVID-19 even though outcome in general seems good in newborns (1).

    1. Coronado Munoz, A., Nawaratne, U., McMann, D., Ellsworth, M., Meliones, J. and Boukas, K., 2020. Late-Onset Neonatal Sepsis in a Patient with Covid-19. New England Journal of Medicine, 2020 Apr 22. doi: 10.1056/NEJMc2010614