Perinatal Maternal-Fetal/Neonatal Transmission

of COVID-19: A Guide to Safe Maternal and

Neonatal Care in the Era of COVID-19
and Physical Distancing
Marie Altendahl, BA,* Yalda Afshar, MD, PhD,† Annabelle de St. Maurice, MD,‡ Viviana Fajardo, MD,* Alison Chu, MD*
*Department of Pediatrics, Division of Neonatology and Developmental Biology, David Geffen School of Medicine at UCLA, Los Angeles, CA
†
Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA
‡
Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA

Education Gaps
Because of their unique immunologic and physiologic states, pregnant
women and neonates may be at risk for worse outcomes related to COVID-19
infection. Unfortunately, the outcomes specific to pregnant women and their
neonates are understudied. Clinicians should be able to recognize and
describe the clinical presentations and outcomes of COVID-19 in pregnant
women and neonates and recognize the potential risks of maternal-fetal and
maternal-neonatal transmission of SARS-CoV-2.

Abstract
AUTHOR DISCLOSURE Drs Altendahl, Afshar, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus
de St. Maurice, Fajardo, and Chu have
responsible for coronavirus disease 2019 (COVID-19), is highly contagious and can
disclosed no financial relationships relevant to
this article. This commentary does not contain cause serious respiratory illness and other clinical manifestations. The aim of this
a discussion of an unapproved/investigative review is to summarize the clinical presentation, diagnosis, and outcomes of
use of a commercial product/device.
COVID-19 in pregnant women and neonates, who may be especially vulnerable to
ABBREVIATIONS the effects of COVID-19, and to discuss what is known about potential maternal-
AAP American Academy of fetal and maternal-neonatal transmission of SARS-CoV-2.
Pediatrics
ACE2 angiotensin-converting
enzyme 2
CDC Centers for Disease Control Objectives After completing this article, readers should be able to:
and Prevention
COVID-19 coronavirus disease 2019 1. Describe the clinical presentations, diagnoses, and outcomes of COVID-19
ECMO extracorporeal membrane
infection in pregnant women and neonates.
oxygenation
ICU intensive care unit 2. Describe the current obstetric and neonatal management of COVID-19.
MERS Middle East respiratory
syndrome 3. Recognize the potential for SARS-CoV-2 transmission during pregnancy,
MIS-C multisystem inflammatory delivery, breastfeeding, and at-home childcare.
syndrome associated with
COVID-19 4. Identify methods to reduce the vertical and horizontal transmission of
PCR polymerase chain reaction SARS-CoV-2 from the pregnant woman to the neonate.
RT-PCR reverse transcriptase
polymerase chain reaction
SARS severe respiratory syndrome
SARS-CoV-2 severe acute respiratory
syndrome coronavirus 2

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 EPIDEMIOLOGY OF COVID-19 IN PREGNANT WOMEN
AND CHILDREN
Starting in December 2019, increasing numbers of patients
were reported to be admitted to hospitals in Wuhan,
Hubei Province, China, with a pneumonialike disorder of
unknown etiology. (1)(2)(3) By the end of January 2020, it
was estimated that over 7,734 cases had been confirmed in
China, and similar cases had been identified in numerous
countries around the world. (1) The illness, known as
coronavirus disease 2019 (COVID-19), is caused by a novel
b-coronavirus called severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2). The condition was associated
with symptoms such as fever, dry cough, shortness of
breath, weakness, and diarrhea. (1)(2)(4)(5) By the beginning
of August 2020, over 18 million people worldwide had been
infected with SARS-CoV-2, and 690,181 (3.8%) infected
individuals had died globally. (6)
SARS-CoV-2 is thought to affect the respiratory system by
binding to the angiotensin-converting enzyme 2 (ACE2)
receptor. (7)(8)(9) The ACE2 receptor is highly expressed in
lung tissue; thus, binding of SARS-CoV-2 allows for the virus
to be transported into lung epithelia, subsequently damaging
the infected tissue. (9)(10) In adult patients with severe
COVID-19, lymphopenia has been observed and substan-
tially elevated proinflammatory cytokines, termed “cyto-
kine storm,” are thought to contribute to further lung tissue
injury. (7)(8)(9)(11) SARS-CoV-2 is highly contagious and
mainly transmitted via respiratory droplets, though it can
be airborne under some conditions. (2)(9)(12)(13) SARS-
CoV-2 is estimated to have a reproduction number ranging
from 2.2 to 5.7, meaning that without sustained physical
distancing measures 1 person with COVID-19 can infect,
on average, 2.2 to 5.7 other individuals. (2) Importantly, the
reproduction number of SARS-CoV-2 can drastically be
reduced to below 1 if appropriate measures are taken (ie,
mandatory mask wearing in public, cancellation of social
gatherings, stay-at-home policies, and universal symptom
screening). (14) Because of the severe respiratory complications
caused by SARS-CoV-2 and its highly contagious nature, preg-
nant women and neonates may be 2 populations at risk for
serious complications related to COVID-19. (5)
Few studies have investigated how pregnancy and infancy
modify the risks associated with COVID-19. (15) During
pregnancy, women have changes in cellular immunity, which
make them more susceptible to severe infections. (16)(17)
Furthermore, physiologic changes in the cardiovascular and
respiratory systems during pregnancy increase the risk for
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adverse effects of respiratory infections. (16)(17)(18)(19) New-
borns are also vulnerable to respiratory infections because
their immature immune systems are still developing. (5)(20)
(21)(22) The aim of this review is to discuss what is known
about the potential for perinatal maternal-fetal and maternal-
neonatal transmission of SARS-CoV-2 and offer evidence-
based guidelines for safe maternal and neonatal care during
the COVID-19 pandemic.
CLINICAL PRESENTATION, DIAGNOSIS, AND
OUTCOMES IN OBSTETRIC PATIENTS WITH COVID-19
Clinical Presentation and Diagnosis in Pregnant Women
Pregnant and nonpregnant women have similar manifes-
tations of COVID-19 symptoms. Both present with symp-
toms such as fever, dry cough, sore throat, myalgia, malaise,
gastrointestinal symptoms, anosmia, and shortness of breath.
(18)(19)(23) Pregnant women most frequently report experi-
encing dry cough (65.6%), fever (48.3%), myalgia (37.9%),
or no symptoms at all (33%). (3)(23) The Centers for Disease
Control and Prevention (CDC) surveillance data showed that
in 91,412 women of reproductive age (15–44 years) who were
infected with SARS-CoV-2, there were no differences in the
frequency of cough or shortness of breath between pregnant
and nonpregnant women. Interestingly, pregnant women
reported headaches, muscle aches, fevers, chills, and
diarrhea symptoms less frequently than their nonpreg-
nant counterparts. (16) Of particular importance is the
large percentage of asymptomatic SARS-COV-2–positive
pregnant patients. First described in the epicenter in New
York, Breslin et al reported that 14 (33%) of 43 pregnant
women testing positive for COVID-19 were asymptomatic
or presymptomatic at the initial COVID-19 testing. (23)
Therefore, universal diagnostic testing for COVID-19 via a
nasopharyngeal swab for polymerase chain reaction (PCR)
is encouraged for all hospitalized pregnant women in
locations where the prevalence of SARS-CoV-2 is high,
to prevent potential nosocomial spread to other patients as
well as health care workers. (23)
Outcomes of COVID-19 in Pregnant Women
Although the prognosis of COVID-19 infection is favorable
in most pregnant women, (24) recent research raises con-
cerns that pregnant women may be at greater risk for severe
COVID-19–related morbidities than their nonpregnant
counterparts. (16)(25) Even though up to 86% of obstetric
patients with COVID-19 report mild symptoms, pregnant
women, particularly those who are overweight or obese, are
 more vulnerable to severe SARS-CoV-2 infection. (16)(23)
(25) The CDC surveillance data found that pregnant women
with COVID-19 were 5.4 times more likely to be hospital-
ized, 1.5 times more likely to be admitted to the intensive
care unit (ICU), and 1.7 times more likely to undergo me-
chanical ventilation than nonpregnant women with COVID-
19. (16) In this study, the reason for hospitalization was not
disclosed, thus it is impossible to determine if increased
rates of hospitalizations in pregnant women with COVID-
19 were related to SARS-CoV-2 infection or pregnancy
itself, such as childbirth. Similarly, Sentilhes et al described
a higher proportion of severe morbidity in pregnant women
with COVID-19 than in the general obstetric population.
(25) In 54 pregnant women with COVID-19, 24.1% required
oxygen supplementation and 9.3% were admitted to the
ICU. (25) The most severe cases reported by Sentilhes et al
occurred in pregnant women more than 35 years of age or
with comorbidities such as asthma or obesity. (25) Individual
case reports of pregnant women with severe adverse out-
comes related to COVID-19 have also been reported. Hosier
et al described a 35-year-old woman with COVID-19 at 22
weeks’ gestation who presented with preeclampsia, placen-
tal abruption, and disseminated intravascular coagulopathy.
SARS-CoV-2 invasion of the placenta was noted, which
contributed to placental inflammation, early-onset pre-
eclampsia, and worsened maternal health. (26) Evidence
has shown life-threatening complications of SARS-CoV-2
infection in obstetric patients, especially those older than 35
years or with comorbidities; thus all pregnant women need
to be counseled on symptoms associated with COVID-19
and should immediately contact their physician if they
become symptomatic.
It is hypothesized that COVID-19 may exacerbate co-
morbidities common to pregnancy such as hypertensive
diseases of pregnancy, coagulopathies, and respiratory
changes, which can lead to an increased risk of preterm
deliveries among pregnant women with COVID-19. (8)(18)
(23)(26)(27)(28)(29)(30) Pierce-Williams et al found that
88% of women with severe COVID-19 infections had pre-
term deliveries. (31) Other studies have reported preterm
deliveries in 24% to 47% of pregnant women who had
symptoms of COVID-19. (25)(32) Many of these deliveries
were iatrogenic and not associated with spontaneous pre-
term labor; however, systemic illness in general, has been
shown to increase the rate of preterm labor and preterm
delivery. (33)
At this time, for pregnant women who have been infected
with COVID-19, obstetrical professionals should obtain
serial fetal growth scans and evaluate amniotic fluid volume
2 weeks after symptom resolution, for the theoretical
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concern of fetal growth restriction with SARS-CoV-2 infec-
tion. Data on the usefulness of routine antenatal surveil-
lance (with biophysical profile or nonstress test) is
unclear for SARS-CoV-2–infected pregnant women. Fur-
thermore, COVID-19 status is not an indication for delivery,
and the delivery mode should be dictated by routine obstet-
rical indications. (32) If preterm labor begins, the decision
about magnesium sulfate for fetal neuroprotection at less
than 32 weeks’ gestation must be individualized. This is
especially important in COVID-19–positive patients with
renal injury, who undergo intubation and are receiving
benzodiazepines, and those with hypervolemia, because
of the confounding risks associated with maternal pulmo-
nary edema and COVID-19. (34) The neonatal benefit of
antenatal glucocorticoids for fetal lung maturity for patients
at risk for preterm delivery within a week is very well-
established. (35) In light of COVID-19–specific data, regard-
less of pregnancy, recent evidence supports the use of an
early, short course of glucocorticoids for patients who
require mechanical ventilation or oxygen support. (36) As
such, the National Institutes of Health COVID-19 Treatment
Guidelines Panel recommended 6 mg of dexamethasone for
up to 10 days in patients with COVID-19 who are receiving
mechanical ventilation or supplemental oxygen. This rec-
ommendation does not address pregnant or lactating
women specifically. For this reason, administration of ante-
natal glucocorticoids for fetal lung maturity is recom-
mended for up to 33 6/7 weeks of gestation in patients
anticipated to deliver within 7 days; however, the benefit of
antenatal steroids for late preterm fetuses between 34 0/7
and 36 6/7 weeks’ gestation is not apparent because glu-
cocorticoids have only been investigated with betametha-
sone, not dexamethasone in this gestational age. (37)
Caring for Pregnant Women with COVID-19
For pregnant women with severe COVID-19 illness requir-
ing hospitalization, multidisciplinary care teams, including
maternal-fetal medicine and neonatology, should have dis-
cussions with the patient and family regarding goals of care
should the woman go into preterm labor or become critically
ill. (38) Conversations with the patient and family should
include discussion of prioritization of maternal or fetal life,
in the event that one might be at severe risk if providing care
that benefits the other. Options that should be discussed in
cases of severe maternal hypoxemia include prone position-
ing, advanced ventilatory methods, and extracorporeal
membrane oxygenation (ECMO), especially with lower ges-
tational ages, when delivery would pose significant neonatal
morbidity. (39) Studies to date have not shown that maternal
ECMO poses specific increased risk to the fetus, outside of
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 preterm delivery and need for NICU admission. (40) How-
ever, there are theoretical increased risks to the neonate such
as infection, complications related to maternal bleeding, or
thromboembolic events, as well as altered placental/fetal
hemodynamics (eg, nonpulsatile flow on venoarterial
ECMO), though the long-term outcomes of these infants
have not been reported. (40)(41) These conversations will
allow care teams to appropriately plan the mode of delivery
and minimize potential SARS-CoV-2 exposure to health
care workers by clarifying if resuscitation of an infant is
desired at the extremes of prematurity (gray zone of viabil-
ity). Moreover, these discussions help guide clinical care,
even when there is no immediate threat to the pregnant
woman or fetus, such as regarding administration of mag-
nesium for preterm labor, maternal steroid use (dexameth-
asone for acute respiratory distress secondary to COVID-19 vs
betamethasone for fetal lung maturity), prophylaxis with
unfractionated heparin for thromboembolism, and use of
remdesivir. These care guidelines are described in Table 1.
(42)(43)(44) Otherwise, supportive cardiorespiratory support
to the pregnant woman is always indicated to help support
both nutrient and oxygen provision to the woman and the
growing fetus.
NEONATAL OUTCOMES IN INFANTS BORN TO
MOTHERS WITH COVID-19
Neonates who are born to mothers with COVID-19 and test
negative for SARS-CoV-2 at birth have promising outcomes.
Approximately 2% to 5% of infants born to mothers with
COVID-19 test positive for SARS-CoV-2 infection within 24
to 96 hours after birth and most have favorable outcomes.
(45) Yu et al described 7 neonates born via caesarean delivery
to mothers with COVID-19. (3) All 7 neonates had birth-
weights greater than 3,000 g and Apgar scores between 8
and 9 at 1 minute and 9 and 10 at 5 minutes after birth. One
neonate tested positive for SARS-CoV-2 based on a nucleic
acid test at 36 hours after birth, but no other neonatal
complications were identified. (3) Although most infants
born to mothers with COVID-19 do well, complications
such as respiratory distress and low birthweight may be seen
at higher proportions in neonates born to mothers with
COVID-19 compared with those born to mothers without
COVID-19. (46) Zhu et al reported that of 10 infants born to
9 women with COVID-19, 6 were born preterm, 6 demon-
strated intrauterine fetal distress, 6 had respiratory distress
at birth, and 2 had thrombocytopenia, even though all
infants tested negative for COVID-19 via pharyngeal swab.
(47) In addition, 6 pregnant women who were positive for
COVID-19 presented with preterm labor. Therefore,
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medical teams able to provide care for high-risk neonates
should be available for complicated or preterm deliveries of
neonates born to women with COVID-19, especially for
deliveries in which pregnant women are critically ill. (38)
CLINICAL PRESENTATION, DIAGNOSIS, OUTCOMES,
AND TREATMENT OF NEONATES WITH COVID-19
Clinical Presentation and Diagnosis
In general, COVID-19 is thought to have a child-sparing
pattern, and infected children are largely asymptomatic or
have mild symptoms. (22)(48)(49) Researchers estimate
that only about 1% of all confirmed or suspected COVID-
19 cases have been in children younger than 10 years.
(49)(50) It is hypothesized that pediatric populations with
COVID-19 infections have milder manifestations compared
to adults, because the ACE2 receptor in children may be
immature and have lower binding affinity than in adults.
(48) Children infected with SARS-CoV-2 most commonly
had fever (65%), dry cough/upper respiratory symptoms
(50%), and gastrointestinal symptoms (22%) such as abdominal
pain, nausea, and/or vomiting. (4)(5)(51)(52) It is estimated
that approximately 16% of children infected with SARS-
CoV-2 remain asymptomatic. (5)(51) Although most children
are asymptomatic or report mild symptoms, pediatric multi-
system inflammatory syndrome associated with COVID-19
(MIS-C) has developed in over 145 children in New York City
alone as of May 18, 2020. (53)(54) MIS-C is a severe inflam-
matory syndrome occurring after SARS-CoV-2 infection in
children and is characterized by inflammation of 2 or more
organ systems and can present with severe shock. (53)(54)(55)
Thus, all children with COVID-19 need to be closely moni-
tored for clinical worsening.
Importantly, infants seem more vulnerable to COVID-19
than other pediatric populations. (56) It is estimated that
18% of all pediatric COVID-19 cases are in infants younger
than 1 year. (50) In addition, manifestations of COVID-19 in
neonates are often atypical and insidious. (49)(52) Many
neonates with COVID-19 present with nonspecific symptoms
such as poor feeding, diarrhea, or other mild gastrointestinal
symptoms, making COVID-19 challenging to diagnose in this
population. (22) Further, case reports describe that infants
with COVID-19 may have more severe symptoms than chil-
dren older than 1 year, and can present with late-onset sepsis,
fever, and leukopenia. (56)(57)(58)(59)(60) Because of its
atypical presentation, standardized protocols are important
for the diagnosis of COVID-19 in neonates. Wu et al found
that unlike adults, pediatric patients with COVID-19 did not
have systemic inflammation. (61) Other studies have reported
lymphopenia, neutropenia, and thrombocytosis in neonates
 TABLE 1. Recommended Care Management of Pregnant Women During
the COVID-19 Pandemic
CATEGORY OF CARE RECOMMENDATIONS

Screening and diagnosis Use telehealth appointments when deemed appropriate for prenatal care in all obstetric
patients to limit transmission of SARS-CoV-2 infections to both patients and health care
workers.
If obstetric patients require in-person appointments, screen all patients for COVID-19 symptoms
before each prenatal appointment.
Counsel patients on symptoms associated with COVID-19 and advise patients to contact their
physician if they develop COVID-19 symptoms. (42) If obstetric patients with COVID-19 are
asymptomatic or have mild symptoms, patients should self-quarantine for 10 days and
monitoring in the outpatient setting can be considered.
Test all pregnant women requiring admission to the hospital for active COVID-19 infection via
SARS-CoV-2 reverse transcriptase polymerase chain reaction nasopharyngeal or nasal swab.
Treatment and pharmacologic Provide supportive care, including appropriate fluid and caloric intake. (42)
management For pregnant patients with a known or potential COVID-19 diagnosis who require chest
imaging for improved medical care, avoid withholding radiography and CT. Single
radiographs and CT scans with abdominal shielding expose the fetus to low levels of
radiation and have not been shown to have teratogenic effects. (43)
Administer high-dose corticosteroids, such as dexamethasone, when clinically indicated.
Pregnant women should, however, be monitored for preterm labor. (3)(42)
Recognize that remdesivir, IL-6 modulators, and convalescent plasma administration have not
been extensively studied in pregnant women. Compassionate use of these medications in
pregnant women who are critically ill with COVID-19 can be considered.
Administer prophylactic treatment for venous thromboembolism (unfractionated heparin) to
pregnant women hospitalized for COVID-19. (44)
Individualize care of pregnant women with COVID-19 experiencing labor before 32 weeks’
gestation to determine the efficacy of magnesium sulfate for neuroprotection, especially in
cases of renal injury, intubated patients with benzodiazepine exposure, and hypervolemia.
Administer antenatal glucocorticoids for fetal lung maturity to obstetric patients with COVID-19
before 33 6/7 weeks of gestation who are anticipated to deliver within 7 days; however,
ACOG does not recommend using antenatal steroids after 34 0/7 weeks’ gestation. (35)
Oxygen therapy Monitor oxygen and carbon dioxide levels frequently; maintaining SpO2>95% and PCO2
between 27 and 32 mm Hg (3.6–4.3 kPa). (42)
Administer supplemental oxygenation if a pregnant woman is unable to maintain SpO2>95%
and PCO2 between 27 and 32 mm Hg (3.6–4.3 kPa). (42)
Notify designated airway team immediately of pregnant COVID-19–positive patients at risk for
intubation, as intubation of pregnant individuals may result in oropharyngeal edema and
require additional measures. (42)
Delivery Determine timing and mode of delivery based on routine obstetrical indications. Delivery
should not be used as a treatment to improve maternal respiratory symptoms, except in
cases of maternal cardiac arrest. (27)(42)
Request that the neonatology team attend deliveries of women who are critically ill with
COVID-19 to provide immediate care for potentially high-risk neonates.

ACOG¼American College of Obstetricians and Gynecologists; COVID-19¼coronavirus disease 2019; CT¼ computed tomography; IL-6¼interleukin 6; PCO2
¼partial pressure of carbon dioxide; SARS-CoV-2¼ severe acute respiratory syndrome coronavirus 2; SpO2¼oxygen saturation.

and children with COVID-19. (50)(61)(62)(63)(64) Thus,
potential SARS-CoV-2 infection should be investigated in
neonates presenting with sepsis, lymphopenia, or neutropenia
without an identifiable cause, and neonates with normal
proinflammatory cytokine levels should not be excluded from
SARS-CoV-2 testing. SARS-CoV-2 infection should also be
suspected if infants have at least 1 clinical symptom, chest
radiographic imaging showing ground glass opacities (in term
infants) or pneumonia, or a history of close contact with a
relative or caretaker with confirmed COVID-19. (51)(63) The
diagnosis of COVID-19 can be made in children using reverse
transcriptase polymerase chain reaction (RT-PCR) on naso-
pharyngeal or nasal samples to detect the presence of SARS-
CoV-2. (65)
Outcomes of COVID-19 in Children
Children appear to be less susceptible to COVID-19 than
adults and have good overall outcomes. (4)(52) Children are

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 estimated to begin showing symptoms around 6 days after
infection. (52) Children infected with SARS-CoV-2 may have
fevers that typically resolve within 24 hours and other mild
symptoms dissipating within 1 to 2 weeks, though fecal viral
shedding can persist. (52)(66)(67) Of note, neonates, chil-
dren with underlying conditions, and children with coex-
isting viral infections are especially vulnerable to severe
complications associated with COVID-19. (4)(5) Neonates
may be at an increased risk for COVID-19 symptoms
because of underdeveloped immune systems. (5)(20)(21)(22)
Götzinger et al found that infants younger than 1 month had
more severe manifestations of SARS-CoV-2 infections and
were more likely to be admitted to the ICU. (5) Pandey et al
also found that children younger than 5 years were more
likely to have higher SARS-CoV-2 viral loads than older
children. (68) A recent multicenter, observational cohort
study from New York City described 149 maternal-neonatal
dyads hospitalized from March 1 to May 10, 2020. In this
study, 12% of neonates required admission to the NICU,
with 10% of these neonates delivered preterm and 3%
requiring mechanical ventilation. Of note, neonates born
to symptomatic mothers were more likely to be born pre-
term (16% vs 3%) and require intensive care (19% vs 2%).
(69) The potential complications of COVID-19 in infants
make it imperative for physicians to counsel parents and
caregivers on the symptoms associated with COVID-19 in
neonates and consider testing for COVID-19 if they have
been in close proximity with other infected individuals.
Management
Currently, there are no vaccines proven to be effective
against SARS-CoV-2. (63) Remdesivir is a promising anti-
viral drug that has shown potential benefit against SARS-
CoV-2 infection in adults and is available for compassionate
use in children and pregnant women. (70)(71) Additional
treatments such as convalescent plasma with neutralizing
antibodies and dexamethasone have been studied in adults
and may have some benefit in certain situations. For exam-
ple, in a study of 5 adults who were critically ill with COVID-
19 and treated with convalescent plasma, all 5 patients
had dissipated fevers within 3 days after transfusion, and
improved oxygenation and decreased viral loads within 12
days after transfusion. (72) Though this was a preliminary
study, it shows promising results for the use of neutralizing
antibodies in critically ill patients. However, these treatment
modalities remain unstudied in neonates and as such, there
are no guidelines for their use in neonates and children. It is
important to note that none of these treatments have been
recommended by the World Health Organization or the
CDC in the United States. (63) In children and obstetric
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patients with mild to moderate COVID-19 infection, sup-
portive treatment such as appropriate fluid and caloric
intake and oxygen supplementation are the mainstays of
management. (63)
SARS-CoV-2 Transmission During Pregnancy, Delivery,
and Postdelivery
Maternal-fetal and maternal-neonatal transmission of
SARS-CoV-2 are central concerns during the COVID-19
pandemic. Vertical transmission of viruses can occur via
intrauterine transmission (ie, blood, transplacental), in-
trapartum, or through breastfeeding. (22)(26)(73)(74) Re-
spiratory viruses also can be transmitted postnatally via
droplets from mother to child. (75) In past coronavirus
outbreaks such as severe acute respiratory syndrome
(SARS) and Middle East respiratory syndrome (MERS),
no cases of vertical transmission were reported. (76)(77)
Similarly, early studies on vertical transmission of SARS-
CoV-2 showed that the risk was low, though other recent
studies have indicated biological plausibility of intrauterine
transmission of SARS-CoV-2. (26)(74)(78) To date, it is
believed that most neonates with COVID-19 are infected
through horizontal transmission of SARS-CoV-2 by a parent
or other close contact.
Intrauterine Transmission of SARS-CoV-2
Rates of intrauterine transmission of SARS-CoV-2, if it
occurs at all, are extremely low, though SARS-CoV-2 pla-
cental invasion and cases of probable SARS-CoV-2 intra-
uterine transmission have been reported. (8)(22)(26)(73)(74)
To date, SARS-CoV-2 has not been identified in most samples
of amniotic fluid, umbilical cord blood, or placenta. (18)(77)(78)
Chen et al reported that 6 of 6 samples of amniotic fluid and
umbilical cord blood tested for SARS-CoV-2 from symp-
tomatic pregnant women with confirmed COVID-19 infec-
tions were negative. (79) Similarly, Simões E Silva et al
found that the SARS-CoV-2 virus was not detected in 18 of 18
samples of amniotic fluid, umbilical cord, and/or placenta
across 5 different studies. (77) In addition, Simões E Silva
et al found that 85 (95.5%) of 89 neonates tested negative for
SARS-CoV-2 via nasopharyngeal swab performed within
0 hours to 9 days after birth to mothers with COVID-19,
thus providing evidence that intrauterine transmission of
SARS-CoV-2 is unlikely. (77) In 4 of the 5 neonates who
tested positive for SARS-CoV-2, swabs were collected 3 to 9
days after birth and 3 of the 4 neonates were in close contact
with infected mothers after birth; thus, intrauterine trans-
mission could not be assumed and SARS-CoV-2 infection
was likely the result of horizontal transmission. (60)(77)(80)
Importantly, all of these studies have small sample sizes and
 vary in their inclusion criteria as well as their mode of
detection of infection in the neonate.
Although rare, cases of transplacental transmission and
reports of SARS-CoV-2 in amniotic fluid, placenta samples,
and positive nasopharyngeal swabs at birth indicate that
intrauterine transmission may be possible. Vivanti et al
reported a case of transplacental transmission of SARS-
CoV-2 in a 23-year-old pregnant woman with known SARS-
CoV-2 infection. (78) At birth, SARS-CoV-2 was identified via
RT-PCR in samples of amniotic fluid, placental tissue,
maternal and neonatal blood, and neonatal nasopharyngeal
swab. The viral load detected in placental tissue was
substantially higher than that found in amniotic fluid
or maternal blood. Immunohistochemistry of placental
tissue also showed considerable invasion of trophoblastic
cells by SARS-CoV-2 and coexisting placental inflammation.
Evidence of high viral load in placental tissue and presence
of SARS-CoV-2 in trophoblastic cells support transplacental
transmission in this case of neonatal congenital infection.
(78) Patanè et al described 2 neonates testing positive for
SARS-CoV-2 at birth. (74) In both cases, invasion of the fetal
side of the placental tissue by SARS-CoV-2 was observed. (74)
Similarly, Hosier et al reported a case in which SARS-CoV-2
was identified in the syncytiotrophoblast of the placenta,
though fetal lung, heart, liver, and kidney tissues were
negative for SARS-CoV-2. (26) Zamaniyan et al also reported
that amniotic fluid collected during cesarean delivery of a
pregnant woman with COVID-19 tested positive for SARS-
CoV-2 on RT-PCR. (81) These reports demonstrate that
intrauterine transmission of SARS-CoV-2 may be possible.
Further research on the incidence of intrauterine transmis-
sion, with an emphasis on transplacental transmission, is
imperative.
All neonates born to mothers who are infected with or
suspected to have COVID-19 should be tested for COVID-19
via nasopharyngeal or nasal swab RT-PCR and monitored
for COVID-19 symptoms after delivery. (82) The CDC re-
commends testing the neonate at approximately 24 hours
of age, then again at 48 hours of age if the initial test results
are negative. (82) Importantly, the optimal timing for testing
the neonate remains unclear, and early testing can increase
the chances of both false positives (ie, contamination of the
naso-/oro-pharynx by SARS-CoV-2 RNA in maternal fluids)
and false negatives (RNA may not be immediately detectable
after birth). (82) Caregivers for these neonates should use
appropriate personal protective equipment until testing
confirms lack of infection. Also, large-scale studies need
to test amniotic fluid, umbilical cord blood, placental tissue,
and neonatal pharyngeal swabs for SARS-CoV-2 to deter-
mine the rate of intrauterine transmission.
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SARS-CoV-2 Transmission During Delivery
Maternal-neonatal transmission of SARS-CoV-2 is unlikely
in both vaginal and cesarean deliveries. (18)(42)(83) A large
proportion of deliveries for obstetric patients with COVID-
19, especially those who are critically ill, have been via
cesarean section. (19)(24)(83)(84) Khoury et al reported that
in a cohort of 241 pregnant women with COVID-19, 41.5%
had cesarean births. In the same study, obstetric patients
with severe or critical manifestations of COVID-19 were
more likely to be delivered via cesarean section than those
who were asymptomatic or had mild COVID-19 infection.
(85) However, given the lack of evidence that cesarean
delivery is superior to vaginal delivery for pregnant women
with COVID-19, the potential short- and long-term risks of
cesarean delivery for both the woman and neonate are
important to consider. Obstetric patients with COVID-19
who had cesarean deliveries were more likely to experience
worse postpartum complications than those who had vag-
inal deliveries. (86) Moreover, cesarean delivery requiring
transportation of patients from the ICU to the operating
room may increase the risk of SARS-CoV-2 transmission to
both hospital workers and other patients. (83) Vaginal
delivery has been proven safe for both pregnant women
with COVID-19 and their neonates. (86) SARS-CoV-2 has
not been identified in vaginal secretion samples (18)(77)(87)
and has only been identified in a few fecal samples from
pregnant women, (18)(87) reducing the likelihood of mater-
nal-neonatal transmission during delivery. Successful vag-
inal deliveries have been reported, even in patients critically
ill with COVID-19, and so, mode of delivery should be
dictated by routine obstetrical indications and not the COV-
ID-19 status of the pregnant woman. (43)(83)
Transmission of SARS-CoV-2 Through Breast Milk
It is unlikely that SARS-CoV-2 is transmitted through breast
milk. (88) In previous coronavirus epidemics, both SARS
and MERS were not identified in breast milk. (76) Similarly,
SARS-CoV-2 was not detected in 63 of 64 breast milk
samples examined in 18 women with COVID-19 via RT-
PCR. (88) Other individual cases of SARS-CoV-2 in breast
milk have been identified in China and Germany, though
mothers were not wearing masks during breast milk col-
lection and the sample may have become contaminated.
(89) The safety of breastfeeding by mothers with COVID-19
is further supported by the findings of Salvatore et al who
observed that in 64 infants breastfed by mothers with
COVID-19 who used surgical masks and washed their
hands and breasts before feeding, all infants tested negative
for SARS-CoV-2 at 5 to 7 days and 14 days after birth. (90)
Vol. 21 No. 12 DECEMBER 2020 e789
 Though current research results show promise for the safety
of breastfeeding by mothers with COVID-19 if proper
precautions are followed, further research is still needed
to investigate how detection and viral load of SARS-CoV-2 in
breast milk may change as a mother’s SARS-CoV-2 infection
progresses.
Current research indicates that the risk of transmission
through breast milk remains low and thus, breastfeeding
should be supported for all mothers and neonates. (45)
Breast milk is very important for the proper nutrition and
immunologic development of the neonate. (89) However,
breastfeeding requires close maternal-neonatal contact
that can potentially increase the risk of transmission. If
mothers with COVID-19 wish to directly nurse their infants,
physicians need to advise parents on the risks of trans-
mission of SARS-CoV-2 during in-person breastfeeding and
preventive measures must be followed, including washing
of hands and breasts, wearing masks during feeding, and
the use of a well-ventilated room during feeding. (45)(89) In
accordance with the American Academy of Pediatrics (AAP)
recommendations, mothers infected with SARS-CoV-2
should breastfeed, either directly or through expressed
breast milk. (89)(91)(92) When expressing breast milk,
mothers should practice proper hygiene including mask
wearing and thorough washing of hands, breasts, pumps,
and bottles. Ideally, expressed breast milk can be fed to the
neonate by an uninfected caregiver, as recommended by the
AAP. (45)(91)

TABLE 2. Recommended Guidelines for Delivery and Postdelivery

Neonatal Care in Obstetric Patients with COVID-19
PATIENTS RECOMMENDATIONS

Asymptomatic COVID-19–positive
obstetric patients and obstetric
patients with mild COVID-19
symptoms
Obstetric patients with severe or
critical COVID-19 symptoms
Delivery: Vaginal delivery of asymptomatic patients or patients with mild COVID-19 should be
promoted when cesarean delivery is not clinically indicated. (42)(83)(94)
Rooming: Neonates can safely room-in with mothers with COVID-19 if proper precautions are
taken. The neonate should remain 6 feet from the infected mother and ideally be placed in a
closed incubator. (8)
Breastfeeding: Neonates born to mothers with COVID-19 should be breastfed, ideally using
expressed breast milk fed to the neonate by an uninfected caregiver using a bottle. (91)
When expressing breastmilk, mothers should practice proper hygiene including mask
wearing and thorough washing of hands, breasts, pumps, and bottles. Mothers who prefer to
directly nurse their infants should follow stringent hygiene measures, including washing of
hands and breasts, wearing masks during feeding, and the use of a well-ventilated or
negative pressure room during feeding. (89)
NICU policy: If the neonate requires NICU admission, only noninfected parents should be
allowed to visit the NICU if they have not developed symptoms and have not tested positive
for COVID-19. (8) Visiting parents should practice proper hand hygiene, wear masks, and stay
next to their neonate while in the NICU. (8) Parents with COVID-19 should not be allowed to
visit until they have properly isolated for 10 days after onset of symptoms or date of positive
RT-PCR test and have been afebrile for 24 hours. (91)(94)(95)
Delivery: Timing of delivery should be individualized and based on maternal status, critical
illness, gestational age, and shared decision-making with patient and/or health care proxy.
Need for mechanical ventilation of the pregnant woman is not an indication for delivery.
(42)(83)
Rooming: Neonates should be allowed to room-in with mothers with suspected or confirmed
COVID-19. Mothers should maintain a reasonable distance from infants when possible. When
providing hands-on care, the mothers and noninfected partners/other family members
should wear masks and use appropriate hand hygiene. If separation is not possible, the
neonate can be placed in a closed isolette to facilitate distancing and for additional
protection. (8)
Breastfeeding: Neonates born to mothers with COVID-19 can be breastfed or receive breast milk
by having an uninfected caregiver provide expressed breastmilk to the neonate using a
bottle. (91) When expressing breastmilk or breastfeeding, mothers should practice proper
hygiene including mask wearing and thorough washing of hands, breasts, pumps, and
bottles.
NICU policy: Some parents may choose to use formula or breast milk provided by a milk bank.
Though not preferred, if this is the only option, all bottles for feeding require extensive
cleaning before use, as per standard practice. (96)

COVID-19¼coronavirus disease 2019; RT-PCR¼ reverse transcriptase polymerase chain reaction.

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 Horizontal Transmission of SARS-CoV-2
Close contact with an infected person, usually the parent, is
the most likely cause of SARS-CoV-2 transmission to a
neonate. In a study of 582 children positive for COVID-19,
infected parents were identified as the infection source in
56% of cases. (5) Wu et al found that 95.6% of COVID-19
cases in children were caused by transmission from an
infected parent. (62) Physical distancing from infected family
members is extremely challenging, especially for parents of
newborns. Maternal-neonatal skin contact has lifelong men-
tal, emotional, and physical health benefits. (8) To prioritize
skin-to-skin contact while also preventing possible SARS-
CoV-2 transmission between the neonate and a mother with
a known or suspected SARS-CoV-2 infection in the imme-
diate postpartum period, we recommend working with
parents and the health care team to balance the risks and
benefits of various rooming options while the dyad is still
hospitalized after delivery. (82) To facilitate this decision, the
CDC recommends that care teams discuss with parents the
benefits of rooming-in, such as improved mother-infant
bonding, identification of infant feeding behaviors, and
improved family-centered care. (82) Of note, infants room-
ing-in with mothers with COVID-19 are not at increased risk
for contracting SARS-CoV-2 when proper prevention mea-
sures are followed compared with infants who are separated.
(45) If the neonate is healthy and the mother with COVID-19
has mild-to-moderate symptoms, the neonate can safely
room with the infected mother and the mother should
maintain a reasonable distance from the infant when pos-
sible. The neonate can be placed in a closed isolette at least 6
feet from the mother, if needed, to facilitate distancing.
(8)(82) When the mother is holding or breastfeeding her
neonate, she should wear a mask and practice proper hand
hygiene. (8) Importantly, neonates should not wear face
shields or masks. (82) If the neonate requires NICU admis-
sion, the neonate should be isolated until viral tests are
confirmed negative, with consideration to continue isolation
practices up to 14 days after birth. Appropriate precautions
should be used in the decision to allow the noninfected
parent to visit the NICU, balancing the risks of exposure to
the infected individual with an appropriate observation
period without symptoms. (8) Visiting parents should prac-
tice proper hand hygiene, wear masks, and stay next to their
neonate while in the NICU. (8) Any parent testing positive
for COVID-19 should not be allowed in the NICU unless
that parent meets criteria for discontinuing home isola-
tion. (8) See Table 2 for more recommendations.
After a mother with COVID-19 and an uninfected neo-
nate are discharged from the hospital, home isolation and
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physical distancing should be practiced until the mother’s
symptoms have improved and she remains afebrile for 24
hours and has been isolated for 10 days since symptom
onset. (93) When possible, the infected mother should
maintain a physical distance of at least 6 feet from her
child and should practice hand hygiene and mask wearing
when caring for the infant. Other household members with
suspected SARS-CoV-2 infection should immediately get
tested for SARS-CoV-2 and follow the CDC’s home isolation
and physical distancing guidelines before caring for the
infant. (93) Parents should be counseled on the symptoms
and risks of COVID-19 in neonates and immediately contact
their physician should SARS-CoV-2 infection be suspected.
CONCLUSIONS
SARS-CoV-2, the virus responsible for COVID-19, is highly
contagious and can cause serious respiratory illness. Research
indicates that pregnant women may be at risk for more severe
SARS-CoV-2 infection, and COVID-19 may lead to preterm
deliveries, especially in critically ill pregnant women. Young
children, especially neonates, may also be at risk for more
severe manifestations of COVID-19. Though maternal-fetal
vertical transmission is possible, it seems unlikely. Rather, close
contact with an infected individual in the immediate postnatal
period is more likely responsible for SARS-CoV-2 infections in
neonates. Parents and health care professionals need to work
together to balance the risks and benefits of skin-to-skin contact
and breastfeeding. The recommendations in this review article
are not definitive given the small sample sizes in studies
published so far on pregnant women and infants and COV-
ID-19. Further research is needed to determine the risks of
COVID-19 in pregnant women and infants and to investigate
the possibility of intrauterine transmission of SARS-CoV-2.
American Board of Pediatrics
Neonatal-Perinatal Content
Specifications
• Identify risks associated with SARS-CoV-2 infections in both
obstetric patients and neonates.
• Identify care management recommendations for obstetric
patients and neonates with COVID-19.
• Recognize the possible modes of transmission for maternal-fetal
and maternal-neonatal transmission of SARS-CoV-2.
• Describe current recommendations about breastfeeding,
rooming-in, and NICU visitation to limit transmission of SARS-
CoV-2 to patients and healthcare workers.
Vol. 21 No. 12 DECEMBER 2020 e791
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