Routes of transmission
Transmission of SARS-CoV-2, the virus that causes COVID-19, to neonates is thought to occur primarily through respiratory droplets during the postnatal period when neonates are exposed to mothers or other caregivers with SARS-CoV-2 infection. Limited reports in the literature have raised concern of possible intrauterine, intrapartum, or peripartum transmission, but the extent and clinical significance of vertical transmission, which appears to be rare, is unclear. At this time, there are insufficient data to make recommendations on routine delayed cord clamping or immediate skin-to-skin care for the purpose of preventing SARS-CoV-2 transmission to the neonate.
Clinical presentation and disease severity
Reported signs among neonates with SARS-CoV-2 infection include fever, lethargy, rhinorrhea, cough, tachypnea, increased work of breathing, vomiting, diarrhea, and poor feeding. The extent to which SARS-CoV-2 infection contributed to the reported signs of infection and complications is unclear, as many of these findings are common in term and preterm infants for other reasons (e.g., transient tachypnea of the newborn, neonatal respiratory distress syndrome).
Current evidence suggests that SARS-CoV-2 infections in neonates are uncommon. If neonates do become infected, the majority have either asymptomatic infections or mild disease (i.e., do not require respiratory support), and they recover. Severe illness in neonates, including illness requiring mechanical ventilation, has been reported but appears to be rare. Neonates with underlying medical conditions and preterm infants (<37 weeks gestational age) may be at higher risk of severe illness from COVID-19.
Testing is recommended for all neonates born to mothers with suspected or confirmed COVID-19, regardless of whether there are signs of infection in the neonate. For neonates presenting with signs of infection suggestive of COVID-19, as described above, providers should also consider alternative diagnoses.
Diagnosis should be confirmed by testing for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR). Detection of SARS-CoV-2 RNA can be collected using nasopharynx, oropharynx, or nasal swab samples.
Serologic testing is not recommended at this time to diagnose acute infection in neonates.
When to test
Both symptomatic and asymptomatic neonates born to mothers with suspected or confirmed COVID-19, regardless of mother’s symptoms, should have testing performed at approximately 24 hours of age. If initial test results are negative, or not available, testing should be repeated at 48 hours of age.
For asymptomatic neonates expected to be discharged at <48 hours of age, a single test can be performed prior to discharge, between 24-48 hours of age.
Prioritization of testing
In areas with limited testing capacity, testing should be prioritized for neonates with signs suggestive of COVID-19 as well neonates with SARS-CoV-2 exposure requiring higher levels of care or who are expected to have prolonged hospitalizations (>48-72 hours depending on delivery mode).
Limitations and interpretation of testing
The optimal timing of testing after birth is unknown. Early testing may lead to false positives (e.g., if the neonate’s nares, nasopharynx and/or oropharynx are contaminated by SARS-CoV-2 RNA in maternal fluids) or false negatives (e.g., RNA may not yet be detectable immediately after exposure following birth).
Snippet from: cdc.gov/caring for newborns