key: cord-0756991-lr0hjk4y
authors: Krishnamurthy, Ganga; Sahni, Rakesh; Leone, Tina; Kim, Faith; Brooks, Maria Cristina; Morales, Sylvia Villaraza-; Koziakova, Adriana; Mills, Cloyde; Capaci, Chaundra Passehl; Penn, Anna
title: Care of the COVID-19 exposed complex newborn infant
date: 2020-07-21
journal: Semin Perinatol
DOI: 10.1016/j.semperi.2020.151282
sha: 9f2ce48bf5992ee6bdd6b583b45d1f7854dd9624
doc_id: 756991
cord_uid: lr0hjk4y

As we confront COVID-19, the global public health emergency of our times, new knowledge is emerging that, combined with information from prior epidemics, can provide insights on how to manage this threat in specific patient populations. Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), both caused by coronaviruses, caused serious respiratory illness in pregnant women that resulted in adverse perinatal outcomes. Thus far, COVID-19 appears to follow a mild course in the vast majority of pregnant women. A significant proportion of pregnant women appear to be asymptomatic carriers of SARS-CoV-2. However, there is limited information on how COVID-19 impacts the fetus and whether vertical transmission occurs. While these knowledge gaps are addressed, it is important to recognize the highly efficient transmission characteristics of SARS-C0V-2 and its potential for causing serious disease in vulnerable individuals, including health care workers. This review provides perspectives from a single center in New York City, the epicenter of the pandemic within the United States. It offers an overview of the preparations required for deliveries of newborns of mothers with COVID-19 and the management of neonates with particular emphasis on those born with complex issues.

At the time of this writing, the COVID-19 pandemic is racing across the globe with more than 4 million confirmed infections and 285,000 reported deaths 1 . The United States of America leads the world in the number of recorded infections (1.4 million) and deaths (88,730) thus far 2 . The pandemic surged in New York City, the epicenter of the pandemic within the United States in late March and early April 2020, with more than 10,000 new cases/day at its peak 2 . Within 3 weeks of the first identified COVID-19 case in New York City on March 1, thousands of infected individuals were seeking medical care, including pregnant women. Even as the pandemic reached the United States, our understanding of how COVID-19 affects pregnant women and perinatal outcomes was limited. Knowledge of the impact of prior viral respiratory pandemics on pregnant women provided useful lessons as we monitored and prepared for the current public health crisis.

The four coronaviruses that generally circulate in humans-HCoV-NL63, HCoV-229E, HCoV-OC43 and HKU1-cause minor illnesses like the common cold 3 . Two new coronaviruses with greater pathogenic potential have emerged over the past two decades -Severe acute respiratory syndrome associated coronavirus (SARS-CoV) and the Middle East respiratory syndrome coronavirus (MERS-CoV) 3 . A third novel coronavirus, SARS-CoV-2, is the causative pathogen of the current COVID-19 outbreak that is now rapidly spreading across the globe 4 . Through serial genetic evolution, recombination, and adaptation in their natural and intermediate animal host reservoirs, these three novel coronaviruses have acquired more virulent traits and have caused severe disease in human hosts 3 .

The first case of SARS was reported in the Guangdong province in China in November 2002 and spread to 26 countries, infected 8098 individuals and caused 774 deaths before the global threat was contained in July 2003 5 . SARS infection followed a more severe course in pregnant women than in non-pregnant women 6 . Sixty percent of pregnant women with SARS required intensive care unit admission, 40% received invasive mechanical ventilation and 30% died 6 . A pooled estimate of reports of pregnant women 4 with SARS shows a 21% early pregnancy loss and a 38% preterm delivery rate 7, 8 . There was one report of fetal demise and no neonatal deaths were reported. Two infants born several weeks after maternal infection were small for gestational age. It is unclear if the growth restriction was related to maternal illness or high dose steroid treatment. There are no reports of vertical transmission 7, 8 .

Middle East respiratory syndrome was first reported in Saudi Arabia in 2012 9 . Since the original report, there have been 2494 laboratory confirmed cases of MERS with 858 deaths yielding a higher case fatality rate of 34% compared to SARS (10%) 9 . There are limited reports of MERS infections in pregnant women. Of 11 women who were diagnosed with MERS during pregnancy, there were 3 reported deaths, 2 pregnancy losses and 3 premature births, including one neonatal death 10 . Again, there were no reports of vertical transmission 10 .

Our understanding of the impact of COVID-19 on pregnant women and perinatal outcomes continues to develop. Based upon limited and preliminary reports, predominantly from China, the disease course of COVID-19 in pregnant women appears to be unlike SARS or MERS 11, 12 . As in the general population, the vast majority of pregnant women (86%) with COVID-19 experience only mild or moderate symptoms [11] [12] . Moreover, universal screening for COVID-19 at presentation to the labor and delivery ward in our institution has uncovered asymptomatic infection in as many as 33% of expectant women 12 .

At the time of this writing and based upon published reports, we are aware of pregnancy and perinatal outcomes in 460 women with COVID-19 during pregnancy [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . It is very likely that more women were infected during pregnancy than has been reported. There were 13 reported maternal deaths 13, 14, 27 . Fifteen pregnancy losses have been reported to date [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . Of 448 neonates, 112 (25%) infants were delivered prematurely, prior to 37 weeks. There were 5 neonatal deaths including one set of twins born at 24 weeks [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . Birth weight was available in 69 infants, of these 13 neonates were born low birth weight (<2500 grams) [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . Compared to SARS and MERS infections during pregnancy, cumulative and preliminary analysis of published reports suggests that COVID-19 infections in pregnant women result in 5 a lower maternal mortality, fewer pregnancy losses, lower rate of premature births and fewer neonatal deaths (Table 1) .

Questions regarding vertical transmission of SARS-CoV-2 remain unresolved. Pooled estimate from published data to date report 28 positive results from 418 nasopharyngeal swab tests for SARS-CoV-2 in neonates [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . While there are no reports of SARS-CoV-2 identified in amniotic fluid, umbilical cord blood or breast milk, there are 3 reports at the time of writing, of placental invasion of the virus [28] [29] [30] .

Studies have detected IgM in newborns suggesting intrauterine infection but the sensitivity and specificity of these tests are unknown 16 . Moreover, intrapartum transmission through aspiration of the virus during cesarean or vaginal delivery cannot be excluded 25 . These conflicting findings support the need for additional studies to assess the risk of vertical transmission of SARS-CoV-2. For the time being, as this is an unresolved question, health care providers should continue to exercise appropriate precautions while caring for neonates born to mothers with COVID-19 until infection in the neonate has been excluded.

The sections that follow provide recommendations and considerations for the care of neonates born to COVID-19 positive mothers.

During the SARS epidemic in 2003, significant risk of transmission of infection to healthcare workers was recognized especially during aerosolizing procedures such as endotracheal intubation 31 .

Modifications to usual resuscitation practices were developed through a simulation process of critical events in Toronto during that epidemic 32 . The practices developed in that process have informed practices during the current COVID-19 pandemic with modifications for different populations and environments.

At the time of birth, healthcare workers are exposed to two patients, the mother and the newborn infant. Even in the absence of vertical transmission, healthcare workers caring for the newborn infant could be exposed to maternal secretions carrying viral particles that remain present on the infant or to 6 droplet or airborne particles transmitted from the mother. Healthcare workers must take precautions to prevent viral transmission while also ensuring appropriate high-quality care to both the mother and newborn.

One of the principles of performing resuscitation during a highly transmissible infectious disease outbreak is to minimize healthcare worker exposure by utilizing the smallest team that will safely accomplish an effective resuscitation. Neonatal resuscitation at the time of birth varies in intensity depending on the condition of the newborn infant and is predictable based on risk factors. Many hospitals have team structures that allow for different sized resuscitation teams depending on the expected complexity of the resuscitation. When risk factors for neonatal resuscitation are present, the minimal recommended team composition includes 2 providers and increases to 4 or more providers for more complex resuscitations 33 .

During the COVID-19 pandemic, we have modified the neonatal resuscitation team composition based on both the complexity of expected resuscitation and the mother's SARS-CoV-2 test status ( Figure   1 ). In order to minimize team members in the room, we utilize a "reserve" system for some team members to be outside of the room. It is important that the reserve team members are already wearing personal protective equipment (PPE) since the time it takes to don PPE can be 1.5-4.5 minutes 32, 34, 35 . In order to conserve PPE, some items such as the gown may be reused if the team members did not enter the patient's room.

Maintaining a safe environment during a pandemic also includes keeping equipment and materials needed for resuscitation clean and unexposed to infectious particles. At the onset of the COVID-19 pandemic in our institution, we organized dedicated resuscitation carts that include all of the supplies needed for resuscitation of potentially exposed infants, including PPE for the team members. The carts are kept outside the room; a separate team member is designated to pass materials inside the room if needed. We have found that communication between the team inside the room and outside the room is critical to the success of this process. We use mobile phones covered in plastic and place a call using speaker mode prior to the start of resuscitation so that the team members can easily communicate during 7 the resuscitation. The team member who manages the cart is also assigned the task of "Event Recorder" which can only be accomplished with an open line of communication. In addition to the supplies cart, we also keep a dedicated transport incubator near the delivery room so that we can quickly move the infant from the delivery room to the NICU if the infant requires NICU admission.

Many of the interventions of resuscitation can lead to aerosolization of viral particles and therefore could increase the potential for transmission. Mask ventilation and endotracheal intubation are procedures commonly needed during neonatal resuscitation that have been identified as aerosolizing procedures 35 . Modifications to some of these procedures have been suggested to minimize the risk of While these recommendations are not intended for neonatal patients, they do include caution that cardiopulmonary resuscitation could be an aerosolizing procedure and that appropriate PPE should be worn.

They also suggest a two-person technique for mask ventilation, use of a viral filter on resuscitation equipment, and use of a video-laryngoscope for endotracheal intubation. It is likely that recommendations will evolve as more evidence for viral transmission becomes available during this pandemic.

Reported data from infants born to mothers with SARS-CoV-2 infection have generally indicated favorable outcomes [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . To our knowledge, twenty eight neonates thus far had a positive test result from nasopharyngeal swabs [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . Of these, we are aware of three neonates who were born prematurely, delivered between 31-33 weeks 13,14,23 and followed a clinical course consistent with their gestational age.

It is currently unknown if newborns with COVID-19 are at increased risk for severe disease. For these reasons care of preterm infants should continue in accordance with the current standards. However, to protect the NICU health care workers from confirmed or suspected cases of SARS-CoV-2 infection, it is critical to consistently implement care practices that include proper isolation and cohorting, use of appropriate PPE and safe airway/respiratory care. In addition, it is imperative to maintain best feeding and bonding practices to improve overall neonatal outcomes. Thus, NICUs must establish necessary safety and best practices using guidelines from the Centers for Disease Control and Prevention and the American Academy of Pediatrics for the care of infants of COVID-19 positive mothers 37,38 . PPE for Health care workers: Health care workers must wear a gown, gloves, eye protection (face shield or goggles), and surgical face mask when caring for a preterm infant with confirmed or suspected COVID-19. Although N95 respirators can be used when providing direct patient care to these infants, they are required for AGP.

The main issue with providing any type of respiratory support to preterm infants with suspected or confirmed viral infection is the generation of aerosol-containing 9 particles that can spread the disease 39 . This could happen due to the proximity to the infant's upper airway or through leakage from the interface or respiratory circuits. While there is a lack of scientific evidence on the use of various protective measures during AGP in preterm infants, physiology driven methodologies can be utilized for preterm infants with suspected or confirmed SARS-CoV-2 infection.

Manual ventilation: Studies in adults suggest that manual ventilation is not associated with increased risk of viral transmission and there is three times higher risk of acquiring a viral infection during endotracheal intubation compared to manual ventilation 40, 41 . In a simulated adult lung injury model, Hui and colleagues have shown that lower tidal volumes produce less air dispersion 42 . Inexperienced health care workers may increase exhaled air dispersion by 40% during bag-mask ventilation 43 . These data suggest that in preterm infants, avoidance of manual ventilation merely for the purpose of preventing air dispersion may not be necessary. The use of viral/bacterial filters during manual ventilation is effective in reducing viral dispersion 43, 44 . However, the addition of a filter adds weight, increases mask leaks and adds dead space that could interfere with effective ventilation. Thus, in extremely low birth weight infants it may be reasonable to avoid filters during bag and mask ventilation to avoid hypercapnia and its deleterious effects.

Airway care: Oral and nasopharyngeal suctioning are essential parts of airway care in preterm infants.

Available information from systematic review of AGP suggest that airway suctioning is not associated with increased risks of SARS transmission 40 . However, studies in adults suggest that continuous suctioning is more effective in reducing aerosol dispersion as opposed to intermittent suctioning 43 .

Noninvasive respiratory support: NCPAP and NIPPV are used as first line of therapy for many preterm infants requiring respiratory support 45 . Nonetheless, there are concerns that using NCPAP or NIPPV during viral illnesses may result in droplet secretion dispersion as infected aerosols and nosocomial transmission. NIPPV can generate droplets >10 m in size that may deposit onto to the local surfaces that may serve as additional sources of infection 46 . Therefore, during the use of NCPAP or NIPPV essential 10 risk mitigation strategies include: isolation in a well-ventilated negative pressure room with optimal air exchange, use of proper PPE, leakage avoidances around the interface, and addition of viral/bacterial filters on the exhalation port of the bubble NCPAP water reservoir (Figure 3 ). The use of high-flow nasal cannula is not recommended as the high flow may be associated with a significant dispersion of viral particles 47 .

Endotracheal intubation: Tracheal intubation in adults has been shown to be consistently associated with SARS transmission to health care workers 40 . In neonates, no such data is currently available during endotracheal intubation for ventilation or surfactant administration. However, viral transmission is still biologically plausible due to close proximity to an infant's airway during the procedure. Thus, the most skilled available provider should perform this procedure using a cuffed endotracheal tube after donning proper PPE. policies. All visitors must be screened prior to entry into the hospital and prior to entry into the NICU for symptoms consistent with COVID-19 including subjective or measured fever ≥100°F, cough, shortness of breath, sore throat, congestion/runny nose, muscle aches, fatigue, diarrhea, or loss of taste or smell. If the visitor develops symptoms or temperature ≥100°F, they must leave and cannot serve as the designated visitor. All visitors must wear a surgical face mask during their entire visit to the hospital. Visitors must practice hand hygiene before and after donning and doffing their PPE. Visitors' gowns and gloves must be donned before entering the infant's room or bed space and doffed before leaving the infant's room or bed space.

As this pandemic spread swiftly across the globe, hospitals have repurposed existing units to meet the surging demand for adult inpatient beds. In cities across the world, pediatric and cardiac intensive care units have been retooled to become adult intensive care units; staff from these units have been redeployed to care for adult patients. This creates logistical issues. Parents expecting to deliver babies with complex congenital heart defects (CHD) at a particular institution may find themselves redirected to other hospitals where care for pediatric patients continues. In such an environment, it is critical that information about the fetus and heart defect is shared with the new team so that adequate preparations can be made for the management of these complex newborns.

During the COVID-19 pandemic, approximately 25% of deliveries are reported to occur prematurely [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . It is unknown whether decisions to deliver early are for maternal health or fetal distress induced by maternal hypoxia. Deliveries at earlier gestation including early term are associated with higher cardiac surgical mortality and morbidity burden 50 . Neonates ideally are placed within incubators to minimize exposure to health care workers. For full term infants, hyperthermia may occur in such instances due to environmental reasons in addition to PGE-1.

For neonates with d-TGA who require balloon atrial septostomy after birth, such procedures should ideally occur in a negative pressure room with the minimal number of providers required to perform the intervention safely. This generally includes a nurse, intensivist, echocardiographer and interventional cardiologist. All individuals within the negative pressure room should wear appropriate PPE including N95 masks if AGPs are going to be performed.

During the pandemic, local and state regulatory bodies are likely to have prohibited elective surgeries. In addition, operating room staff and equipment including ventilators previously reserved for use for pediatric patients may be in short supply. It is likely that each institution has policies or guidelines for surgical procedures with emergency surgeries taking precedence. Collaboration between maternal fetal medicine, fetal cardiologists, intensivists and surgeons should allow pro-active surgical decision making and timing so that surgery is not delayed. We recommend that surgical date be set after the results of the first COVID-19 test on the neonate performed at 24 hours is available. Transportation to and from the operating room should be done in incubators.

Postoperative care of maternal COVID-19 exposed neonate should be no different from the routine practices of the unit with the exception that these infants will be in closed negative pressure rooms. This environment is certain to pose challenges to the care delivered. Serial bed-side surveillance and frequent examination needed for optimal care of these patients may be difficult with the physical 14 discomfort posed by continual wear of PPE. To limit exposure to health care workers, minimal number of individuals necessary for optimal care should enter the room. Care, diagnostic and laboratory investigations should be clustered to minimize exposure of health care workers. However, although it is unknown, we expect the postoperative course to be no different in the PUI infant. PPE precautions and preparations for resuscitation mentioned in previous sections should be followed.

If surgical intervention is required, a prolonged delay should be avoided. For example, in PUIs who require a surgical procedure such as a CDH repair or a decompression gastrostomy tube placement in a patient with a trachea-esophageal fistula and esophageal atresia, surgery will likely be required in the first week of life, regardless of PUI status. A testing scheme should be established that includes early (~24 hour) PCR testing for virus as well as testing within 24 hours of any planned surgery.

While the timing of surgery may not be altered for a PUI baby, the surgical approach should be carefully considered. There is currently insufficient data recommending for or against an open versus laparoscopy approach specific to COVID-19 51 . Previous research has suggested a potential increase in aerosolization of blood-borne viruses during laparoscopic procedures, but there has been no consistent evidence that this occurs with COVID-19. Therefore, many surgical guidelines recommend choosing the appropriate surgical method individualized to each patient. If that involves a laparoscopic procedure then surgeons should utilize devices to filter released aerosolized particles. All surgical staff should still be aware of the possibility of viral contamination during an open, laparoscopic or robotic surgery and take all protective measures needed to maintain a safe environment to minimize risk of infection 52 .

Pre-operative COVID-19 testing is recommended in patients preferably within 24 to 72 hours prior to a known procedure. With improved widespread availability of testing, our institution's turnaround time for the rapid PCR test is less than four hours, but this may be variable at each center. If the patient is transferred from an outside hospital for a surgical emergency, even if the outside institution's test is negative, if feasible, the test should be performed upon arrival given the risk of an invalid sample. If the procedure is emergent, such as a pneumoperitoneum in a neonate with necrotizing enterocolitis or volvulus, the neonate is presumed a PUI and special consideration should be undertaken by all surgical, neonatal and anesthesia staff to minimize viral transmission. Following surgery, the neonate should still be considered a PUI and placed back in a negative pressure room if available and kept in an incubator until his or her day of life 14 swab returns negative upon which isolation precautions can be lifted 53 .

Although it is well established that SAR-CoV-2 is primarily transmitted via respiratory droplets and contact routes, airborne transmission may be possible in specific circumstances including endotracheal intubation, bronchoscopy, chest tube placement, and tracheostomy-all of which may be required in neonates 54 . Given the asymptomatic nature of the virus in pediatric patients, it is important to recognize that they potentially remain contagious even if asymptomatic. Similar to other surgical groups, the American Academy of Otolaryngology-Head and Neck Surgery recommends limiting care to time-sensitive and emergencies to reduce nosocomial transmission 55 . Similar to above, rapid COVID-19 testing should be performed in the neonate prior to a planned procedure such as a tracheostomy placement or a routine surveillance bronchoscopy.

Although there have been no reported cases of infants requiring ECMO in the setting of a COVID-19 infection, cannulation is still a possibility in a neonate considered a PUI. In emergent cases such as meconium aspiration syndrome, persistent pulmonary hypertension of the newborn or CDH with refractory respiratory failure that occur early in life, it may not be feasible to obtain testing results in a timely manner. Therefore, providers should undertake extreme precaution, adopting consensus guidelines proposed by the Extracorporeal Life Support Organization (ELSO) 56 . It is vital that standard COVID-19 protective measures are followed as recommended by the World Health Organization and other national health organizations during cannulation as well as during ongoing care of an ECMO PUI patient 57 . According to ELSO, standard cannulation techniques should be performed with only essential personnel, ideally in a negative pressure room or at least a single patient room (surgical team, ICU attending and/or fellow, two ICU nurses, one respiratory therapist and one ECMO perfusionist) all wearing standard, contact and airborne PPE. Because electrocautery is an aerosol generating procedure, N95 respirators along with eye protection should be worn by all members present 56 .

Following cannulation, bedside care should be performed with as few personnel as safely possible for optimal care and should optimally be timed with blood draws, cannula dressing changes and patient repositioning. If the patient requires re-assessment, one provider, bedside nurse and perfusionist should assess the patient together to limit multiple entries into the room by several providers. Circuit evaluation and maintenance practices should also occur at the time of bedside cares with circuit adjustment parameters discussed with the medical team on rounds in order to minimize multiple providers entering the room. The role of chest physiotherapy and bronchoscopy during ECMO should be determined by patient need. Inline suction catheters are again indicated and used in association with a cuffed endotracheal tube 56 .

In order to ensure safety and success of cannulation in a PUI, following set guidelines and practicing in the form of simulation or video tutorials will aid in minimizing nosocomial transmission 58 .

Providers should send rapid PCR testing as soon as possible given likelihood that following cannulation, a patient will remain on ECMO for at least a few days if not longer in order to also preserve PPE if the results are negative. In all these cases, there should be constant professional supervision and guidance as well as monitoring strategies to ensure that healthcare workers are aware of their own personal protection while caring for this high-risk neonatal population during the COVID-19 pandemic.

The current COVID-19 pandemic has swiftly surged across the globe. The rapid spread across the world confirms the efficiency with which SARS-CoV-2 is transmitted. It has infected millions including 17 pregnant women, infants and children. Very little is known about the impact of COVID-19 on pregnant women and their newborn infants. Emerging evidence points to a high rate of premature births in women who acquire COVID-19 during pregnancy. We do not yet know the impact of maternal COVID-19 on fetuses with complex cardiac or non-cardiac surgical malformations. As the possibility of vertical transmission exists, providers should exercise caution while caring for these complex newborns until infection has been excluded.

The authors do not have any conflicts of interest. (25) Neonatal death 0/13 (0) 1/9 (11.1) 5/448 (1.1) 

Origin and evolution of pathogenic coronaviruses

Novel Coronavirus Investigating and Research Team. A Novel Coronavirus from Patients with Pneumonia in China

A casecontrolled study comparing clinical course and outcomes of pregnant and nonpregnant women with severe acute respiratory syndrome

Infants born to mothers with severe acute respiratory syndrome

Clinical analysis of pregnancy in second and third trimesters complicated severe acute respiratory syndrome

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection during pregnancy: Report of two cases & review of the literature

Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy

COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of

Maternal Death Due to COVID-19 Disease

Preterm delivery in pregnant woman with critical COVID-19 pneumonia and vertical transmission

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records

A case report of neonatal COVID-19 infection in China

Severe COVID-19 during Pregnancy and Possible Vertical Transmission

A case of 2019 Novel Coronavirus in a pregnant woman with preterm delivery

Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia

Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn

A Case of 2019 novel coronavirus in a pregnant woman with preterm delivery Clin Infect Dis

Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study

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

Asymptomatic COVID-19 infection in late pregnancy indicated no vertical transmission

Vaginal delivery in SARS-CoV-2 infected pregnant women in Northern Italy: a retrospective analysis

Neonatal Late Onset Infection with Severe Acute Respiratory Syndrome Coronavirus 2

Characteristics and outcomes of pregnant women hospitalised with confirmed SARS-CoV-2 infection in the UK: a national cohort study using the UK Obstetric Surveillance System (UKOSS)

First case of placental infection with SARS-CoV-2

Second-Trimester Miscarriage in a Pregnant Woman With SARS-CoV-2 Infection

Detection of SARS-COV-2 in Placental and Fetal Membrane Samples

Cluster of Severe Acute Respiratory Syndrome Cases Among Protected Health-care Workers

Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome

Textbook of Neonatal Resuscitation

The "delay effect" of donning a gown during cardiopulmonary resuscitation in a simulation model

COVID-19 in cardiac arrest and infection risk to rescuers: a systematic review

Covid-19 infection risk to rescuers from patients in cardiac arrest

Initial Guidance: Management of infants born to mothers with COVID-19

Protecting healthcare workers from SARS-CoV-2 infection: Practical indications

Aerosol-generating procedures and risk of transmission of acute respiratory infections: A systematic review

EASE Study consortium. Influenza aerosols in UK hospitals during the H1N1 (2009) pandemic -The risk of aerosol generation during medical procedures

Non-invasive positive pressure ventilation: an experimental model to assess air and particle dispersion

Exhaled air dispersion during bagmask ventilation and sputum suctioning -Implications for infection control

Mask ventilation and dispersion of exhaled air

Preventing continuous positive airway pressure failure: Evidence-based and physiologically sound practices from delivery room to the neonatal intensive care unit

Evaluation of droplet dispersion during noninvasive ventilation, oxygen therapy, nebulizer treatment and chest physiotherapy in clinical practice: implications for management of pandemic influenza and other airborne infections

Exhaled air dispersion and removal is influenced by isolation room size and ventilation settings during oxygen delivery via nasal cannula

Pharmacokinetics of oseltamivir in breast milk and maternal plasma

Gestational age at birth and outcomes after neonatal cardiac surgery: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

Management for patients with pediatric surgical disease during the COVID-19 epidemic

SAGES Recommendations Regarding Surgical Response to COVID-19 Crisis -SAGES

A contingency plan for the management of the 2019 novel coronavirus outbreak in neonatal intensive care units

Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations

Best Practice Recommendations for Pediatric Otolaryngology During the

Extracorporeal Life Support Organization COVID-19 Interim Guidelines

Initial ELSO Guidance Document: ECMO for COVID-19 Patients with Severe Cardiopulmonary Failure

Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China

We sincerely express our gratitude to the hundreds of health care workers including those from our own institution who have worked tirelessly to provide the highest quality care during these unprecedented times. We acknowledge the hard work, dedication and empathy they have demonstrated to each other, our patients and their families during this crisis.Finally, we acknowledge the extraordinary legacy left by one Hero-our inspiring patient care director-Rebecca Adelman, an indirect and unexpected casuality of COVID-19.