key: cord-1049924-9bu8cykv
authors: Shalish, Wissam; Lakshminrusimha, Satyanarayana; Manzoni, Paolo; Keszler, Martin; Sant'Anna, Guilherme M.
title: COVID-19 and Neonatal Respiratory Care: Current Evidence and Practical Approach
date: 2020-05-02
journal: Am J Perinatol
DOI: 10.1055/s-0040-1710522
sha: 2a7de67dca95e98bfb673ab5b91073bdcf89d86d
doc_id: 1049924
cord_uid: 9bu8cykv

The novel coronavirus disease 2019 (COVID-19) pandemic has urged the development and implementation of guidelines and protocols on diagnosis, management, infection control strategies, and discharge planning. However, very little is currently known about neonatal COVID-19 and severe acute respiratory syndrome–coronavirus-2 (SARS-CoV-2) infections. Thus, many questions arise with regard to respiratory care after birth, necessary protection to health care workers (HCW) in the delivery room and neonatal intensive care unit (NICU), and safety of bag and mask ventilation, noninvasive respiratory support, deep suctioning, endotracheal intubation, and mechanical ventilation. Indeed, these questions have created tremendous confusion amongst neonatal HCW. In this manuscript, we comprehensively reviewed the current evidence regarding COVID-19 perinatal transmission, respiratory outcomes of neonates born to mothers with COVID-19 and infants with documented SARS-CoV-2 infection, and the evidence for using different respiratory support modalities and aerosol-generating procedures in this specific population. The results demonstrated that to date, neonatal COVID-19 infection is uncommon, generally acquired postnatally, and associated with favorable respiratory outcomes. The reason why infants display a milder spectrum of disease remains unclear. Nonetheless, the risk of severe or critical illness in young patients exists. Currently, the recommended respiratory approach for infants with suspected or confirmed infection is not evidence based but should include all routinely used types of support, with the addition of viral filters, proper personal protective equipment, and placement of infants in isolation rooms, ideally with negative pressure. As information is changing rapidly, clinicians should frequently watch out for updates on the subject. Key Points: Novel coronavirus disease 2019 (COVID-19) pandemic urged development of guidelines. Neonatal COVID-19 disease is uncommon. Respiratory outcomes in neonates seems favorable. Current neonatal respiratory care should continue. Clinicians should watch frequently for updates.

As of April 12, 2020, the World Health Organization (WHO) had reported nearly 1.7 million people, including thousands of health care workers (HCW), infected with novel coronavirus disease 2019 (COVID- 19) worldwide. In response to the pandemic, hospitals have quickly ramped up efforts to develop and implement guidelines and protocols. These contingency plans have focused on diagnosis, treatment, discharge, and infection control strategies, but preparation and dissemination have been challenged due to paucity of high-quality evidence, rapid pace of new information, and conflicting data. Neonatal intensive care units (NICUs) have been relatively spared so far, and thus very little is currently known about neonatal severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection. Many questions pertaining to the newborn population have arisen, particularly with regard to their respiratory care. What are the chances of vertical transmission of the virus and how should the infant be managed during the immediate postpartum period? What is the optimal management of a preterm infant born to a SARS-CoV-2 positive mother requiring respiratory support immediately after birth? How should HCW protect themselves? What is the optimal approach for managing an extremely preterm infant already on continuous positive airway pressure (CPAP) that develops signs and symptoms suspicious for COVID-19? Can this patient still be safely managed with noninvasive support? If the patient deteriorates, are procedures, such as mask ventilation or deep suctioning, safe or should the infant be immediately intubated? Altogether, these scenarios have created tremendous confusion amongst neonatal HCW (►Fig. 1). These anxieties have been exacerbated further by an inability to simply extrapolate current adult recommendations to neonates, given their remarkably different respiratory physiology and the course itself of COVID-19 disease.

Therefore, we formed an ad hoc working group to develop guidelines on neonatal respiratory care during the COVID-19 outbreak. We comprehensively reviewed the available evidence regarding perinatal transmission of the virus, respiratory outcomes of neonates born to mothers with COVID-19 and those infants with documented SARS-CoV-2 infection, as well as the evidence for using different respiratory support modalities, and aerosol-generating procedures (AGPs) in this specific population. Based on the available data, we provide a practical approach for their respiratory management.

For the literature review, we searched for all studies published between December 1, 2019 and April 12, 2020 using the PubMed search engine, SciELO database, and Google scholar. Search terms included (COVID-19 or SARS-CoV-2) AND (neonate or newborn or infant or pregnancy). Two authors (W.S. and G.S.) reviewed all studies and further retrieved additional articles through reference searching and personal communication. All case reports, case series and cohort studies, describing the characteristics of infants born to mothers with positive SARS-CoV-2 infection and/or characteristics of infected neonates or infants less than 1 year of age were included. Information pertaining to clinical symptoms and adverse events following birth to a mother with positive SARS-CoV-2 or actual infection were gathered. Duplicate case reports were identified whenever possible and only presented once. Moreover, in infants born to mothers with positive SARS-CoV-2, results of investigational tests were described.

To date, the outcomes of 217 neonates (27 publications) born to mothers with positive SARS-CoV-2 have been reported (►Table 1). Of them, 210 (95%) either tested negative for the virus (130/207) or were not tested given their unremarkable postnatal course (80/207). Of the seven remaining infants, three had equivocal test results and four had positive results. Of note, only 30 neonates (14%) were born by spontaneous vaginal delivery, none of which tested positive for SARS-CoV-2 infection.

The vast majority of infants with negative test or not tested were asymptomatic after birth. However, a small proportion exhibited symptoms of common neonatal diseases. Only four infants required respiratory support after birth, 5, 7, 9, 25 of which one required mechanical ventilation (MV) on day 3 of life for frequent desaturations. 17 An additional infant required MV on day 8 of life in the context of shock, multiorgan failure, and subsequent death (negative test at the time of clinical deterioration). 25 Also, there was one reported case of stillbirth attributable to maternal acute respiratory distress syndrome (ARDS) and shock. 17 Three infants had equivocal test results for SARS-CoV-2 despite having an otherwise uneventful postnatal course. 22, 26 All tested negative for SARS-CoV-2 using quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) taken from the infants' nasopharyngeal swabs and serum as well as the maternal vaginal secretions and breask milk. However, they had elevated serum levels of immunoglobulin IgG and IgM antibodies for SARS-CoV-2 after birth. While the presence of IgM antibodies at high levels in the newborn raises the possibility of maternal-infant transmission, the negative RT-PCR results are harder to explain. Moreover, caution is advised when using IgM assays to make the diagnosis of congenital infections since false positives are not uncommon. 28 Only four infants born to mothers with positive SARS-CoV-2 infection had a positive test. 23, 27 However, given that all four infants were only diagnosed between 36 to 48 hours after birth (RT-PCR test from nasopharyngeal swabs), it is impossible to determine whether these infections were acquired in utero or postnatally. Moreover, although strict infectious control measures were reportedly implemented in those four infants, there was insufficient information regarding contact with the mother (or any other family members) and exposure to breastmilk. In the first case, a term infant born by normal delivery to a mother with confirmed COVID-19 had a benign postnatal course except for mild lymphopenia and mildly elevated liver enzymes. 27 Testing for SARS-CoV-2 was positive at 36 hours of life but no respiratory support was needed throughout hospitalization. Importantly, RT-PCR tests performed on placental tissue, umbilical cord blood, and breast milk were all negative. In the second and third cases, 23 two term infants with unremarkable delivery developed fever and lethargy on the second day of life and their RT-PCR was positive at approximately 48 hours after birth. Both infants rapidly improved and did not require respiratory support. In the last case, 23 a preterm infant (31 2/7 weeks' gestation) born by caesarean section for fetal distress had low Apgar's scores, developed respiratory distress syndrome requiring noninvasive support, and later developed 22 Chen Y et al, 3 Li et al, 12 Wang et al, 27 Wu et al, 19 All in all, infants born to mothers with positive SARS-CoV-2 infection generally have favorable outcomes, with no convincing case of vertical transmission, at least when delivery route was caesarean section. In the few cases where infants had a positive or equivocal test, postnatal course was generally uneventful.

Epidemiological data from the countries with the largest number of COVID-19 cases (China, Italy, and the United States of America) have demonstrated that children represent a minority of the overall cases (►Table 2). In a cohort from China of 72,314 individuals with SARS-CoV-2 infection, only 1% of reported cases were children with <10 years of age. 29 Similarly, in a cohort of 22,512 individuals with COVID-19 from Italy, 1.2% of cases were children between the age of 0 and 18 years. 30 More recently, a report from the Centers for Disease Control and prevention in the United States found that out of 149,760 confirmed cases of COVID-19,2,572 (1.7%) were children with <18 years, of which 398 (0.3% of all cases) were <1 year old. 31 While the number of pediatric COVID-19 cases appears to be low, the exact incidence and associated morbidities/mortality of SARS-CoV-2 infection in neonates and young infants are not clear. We identified 18 publications that described the clinical manifestations and outcomes from a total of 856 neonates and infants under 1 year with SARS-CoV-2 infection. 9,15,31-46 All but three were case reports or case series that included fewer than 10 infants <1 year. Of the 48 infants described in these reports, all were either asymptomatic, had mild fever and upper respiratory tract infection symptoms, or mild pneumonia. Only four infants required oxygen supplementation, and none needed additional respiratory support or intensive care. Furthermore, only nine infants were described to have acquired the infection during the neonatal period, 9, 37, 44, 45 and all were either asymptomatic carriers or had mild respiratory symptoms. In the third largest publication, Lu et al described the evolution of 31 infants between the ages of 0 to 1 year with SARS-CoV-2 infection. 40 The majority (80%) presented with pneumonia but did not require any respiratory support. Of note, one infant died from multiorgan failure due to an intussusception. In the most recent CDC report, among 95 infants <1 year with known hospitalization status, 59 (62%) required hospitalization, but only 5 were in intensive care. 31 In the largest pediatric cohort study to date, Dong et al described the clinical characteristics and outcomes of 2,143 children from China with suspected or confirmed SARS-CoV-2 infection, among which 379 (18%) were infants under 1 year. 35 In the latter group, 33 developed severe pneumonia with hypoxemia (requiring respiratory support) and 7 were in critical condition (developed ARDS and shock) but eventually recovered. While this study suggests that close to 10% of infants with ages 0-to 1-year age develop severe or critical illness, it is important to note that only 86/379 infants actually had a confirmed diagnosis of SARS-CoV-2 infection (by RT-PCR or through genomic sequencing). The other 293 infants were suspected cases based on fulfilling clinical, laboratory, or radiological criteria. Considering that the proportion of severe/critical presentations in the study were significantly higher in the suspected, compared with the confirmed COVID-19 cases, this raises the possibility that many of the suspected cases may have been caused by viral pathogens other than SARS-CoV-2. Thus, although the majority of neonates and infants under 1 year with SARS-CoV-2 infection appear to have generally favorable outcomes, the risk of severe or critical illness exists. Intriguingly, the reason why infants display a milder spectrum of disease compared with adults remains unclear and is the subject of ongoing investigations. 47, 48 Terminology The provision of respiratory care remains an integral component of the management of neonates, whether during the transition period after birth or during NICU hospitalization. Respiratory support practices should follow an evidencebased approach for treating patients and protecting HCW from the virus. An important first step is to define neonatal ARDS in the context of suspected or confirmed COVID-19 infection. Is there a specific clinical feature attributable to COVID-19 when dealing with neonatal respiratory distress? In 2017, an international multicenter collaborative produced a consensus definition for neonatal ARDS. 49 This definition might help to standardize the processes for identifying suspected cases of SARS-CoV-2 infection and classifying them according to their illness severity. Moreover, as the number of deaths in neonates positive for SARS-CoV-2 may become increasingly reported, this definition will help to differentiate between deaths attributable to pregnancy complications (e.g., prematurity and asphyxia) and deaths attributable to the infection itself.

In the next section, a practical approach and mostly physiology-based approach to the respiratory care of neonates with suspected or confirmed SARS-CoV-2 infection is provided and summarized in ►Table 3. Of note, for all aspects of respiratory care described below, HCW should use adequate full personal protective equipment (PPE) including a long-sleeved gown, single-use gloves, eye protection, and a N95 mask or the equivalent as the minimum level of respiratory protection.

Specific guidance for respiratory management of COVID-19 in neonates is not yet available as positive infants who needed some support were either premature or affected by comorbidities. Therefore, the true picture of SARS-CoV-2 in neonates will likely arise from further studies and larger case series over the next weeks. Nevertheless, in the meantime, NICUs have to establish guidelines or protocols for respiratory management and necessary precautions.

Delivery Room Management and Transport from the Delivery Room to the NICU As the likelihood of vertical transmission is very low, neonatal resuscitation should be performed according to the Neonatal Resuscitation Program 7th edition, 50 with slight modifications (outlined below) for some respiratory care practices. To minimize HCW exposure, the least number of personnel should enter the delivery room (DR) with standby staff outside the room. Following initial stabilization, the infant should be placed in an incubator and transported via a short, preestablished pathway to the NICU (►Fig. 2).

A major concern when applying any type of respiratory support to patients with suspected or confirmed viral infection is the generation of aerosol-containing particles that can spread the disease. 51 The theoretical risk of aerosol generation and dispersion stems from various factors, including the proximity to the patient's upper airway and risk of dispersion through interface leaks or respiratory circuits. In 2014, the WHO systematically reviewed and graded the evidence for using different protective measures during AGPs. All included studies were of very low quality, and none included neonates. 52 Therefore, in the absence of scientific evidence, a physiology-driven approach in infants with suspected or confirmed SARS-CoV-2 infection is outlined here.

The risk of viral transmission with manual ventilation has only been evaluated in a few adult studies. In a systematic review, manual ventilation (before or after intubation) was not independently associated with increased risk of viral transmission 53 and the odds of acquiring a viral infection were three times higher during endotracheal intubation compared with bagging. 54 In a series of physiological experiments, Chan et al programmed an adult simulator to mimic varying severities of lung injury. 55,56 When a tidal volume (VT) of 300 mL was applied, air dispersion reached up to 0.3 to 0.35 m. Presumably, lower VT would produce less air dispersion. Indeed, in another experiment using noninvasive ventilation, a five-fold decrease in VT was associated with a 30% reduction in air dispersion. 57 Thus, using this nonlinear relationship, mask and bag ventilation of a neonate weighing 3 kg using VT between 15 to 18 mL (16-20 times lower than adults) would generate a small air dispersion of approximately 1.5 to 1.8 cm (►Fig. 3). Technical skills to minimize exhaled air dispersion is also paramount since inexperienced HCW can increase the spread by 40%. 55 Thus, in neonatal respiratory care, avoidance of manual ventilation solely for the purpose of preventing air dispersion appears unnecessary.

To further protect HCW during manual ventilation, several NICUs have also embraced the use of bacterial/viral filters. While the filter is effective in reducing viral dispersion, 55, 56 there are important considerations to its use. For example, addition of a filter can increase the bulk of the device and reduce efficiency by increasing mask leaks. Furthermore, caution is advised when improvising equipment because interposing an adult-sized filter would add approximately 40 mL of dead space, which would result in completely ineffective gas exchange. Even smaller filters add approximately 10 mL of dead space, which could be detrimental to a small preterm infant if kept in place for an extended period (►Fig. 3). Since no positive COVID-19 cases were detected in infants <1,000 g, it may be reasonable to not use filters while applying bag and mask ventilation to these infants to avoid possible iatrogenic hypercapnia with subsequent intraventricular hemorrhage.

Pooled estimates from a systematic review have demonstrated that activities such as suctioning and collection of sputum samples were not associated with increased risks of infection transmission. 53 However, some evidence from adult studies suggests that in nonintubated patients, continuous suctioning may be more effective at reducing aerosol dispersion compared with intermittent suctioning. 55 Noninvasive Respiratory Support CPAP and nasal intermittent positive pressure ventilation (NIPPV) may play a supportive role in infants with viral pneumonia and early ARDS. Considering that some viral infections can convert from droplets to airborne during respiratory therapy, it is possible that CPAP and NIPPV Table 3 Practical approach to neonates with suspected or conformed COVID-19

Delivery room and NICU: should continue to be used as recommended by the NRP, with all protective measures in place for suspected or confirmed cases. A small viral/bacterial filter should be placed in between the T-piece resuscitator or anesthesia bag and the mask or in the expiratory limb (before the PEEP valve) of a self-inflating bag. Normally, the filter should be replaced every 8-12 hours. Note: when placed between the T-piece or anesthesia bag and mask, the filter adds significant dead space. For that reason, the smallest available filter should be used and prolonged ventilation using this apparatus should be avoided. Since no positive COVID-19 cases were detected in infants <1,000 g it may be reasonable to not use filters while applying bag and mask ventilation to these infants to avoid possible iatrogenic hypercapnia with subsequent intraventricular hemorrhage.

Non-intubated infant: continuous suctioning reduces aerosol spread better than several episodes of intermittent suctioning. In this respect, open airway toileting should be performed with continuous suctioning. Mechanically ventilated infants: a closed-circuit suction should be always inline and used for endotracheal suctioning.

Delivery room and NICU: should continue to be used as recommended by the NRP with all protective measures in place for suspected or confirmed COVID-19 cases.

A viral/bacterial filter should be placed in the expiratory limb (before the water reservoir for the bubble system) or before the ventilator exhalation valve. Normally, the filter should be replaced every 8-12 hours.

Noninvasive positive pressure ventilation Delivery room and NICU: is acceptable as long as all protective measures are in place for suspected or confirmed COVID-19 cases.

A viral/bacterial filter should be placed in the expiratory limb of the system. Note: if those measures are not available or reliable, then intubation and mechanical ventilation is a reasonable option.

Delivery room and NICU: is the procedure associated with higher risk of contamination. Therefore, the operator should have experience and be properly protected. If possible, use a video laryngoscopy system to maintain some distance from the patient airway.

NICU: should continue to be used in the NICU as per unit protocols as long as all protective measures are in place for suspected or confirmed COVID-19 cases. There are no data to recommend a specific mode. A viral/bacterial filter should be placed on the expiratory limb before the ventilator exhalation valve (not feasible with high-frequency oscillatory ventilation). Normally, the filter should be replaced every 8-12 hours. A closed ETT suction apparatus should be used.

Abbreviations: COVID-19, novel coronavirus disease 2019; ETT, endotracheal tube; NICU, neonatal intensive care unit; NRP, neonatal resuscitation; PEEP, positive end expiratory pressure. may disperse infected aerosols and contribute to nosocomial transmission. However, during the SARS outbreak, many adult patients were safely and effectively treated with both therapies in hospitals with good infection control measures (proper room air exchange rate and adequate PPE). 54,57, 58 Simonds et al evaluated air dispersion during NIPPV and found generation of droplets of >10 μm in size, 59 suggesting that most droplets deposit on local surfaces within a short distance. While this reduces the risk of viral acquisition by inhalation, these surfaces may serve as a source of infection in the absence of strict precautions. In another experiment in adults, exposure to exhaled air occurred within a 1-m region (0.3-0.85 m) when using three different types of interfaces and VT of 300 mL (16-20 times the VT of a 3-kg infant). 60 Therefore, CPAP and NIPPV appear to be safe in neonates if used in adequately ventilated room, with proper protection measures, careful fitting of the interface, and addition of hydrophobic filter between the interface and water reservoir (bubble CPAP) or exhalation port of ventilators (CPAP or NIPPV). However, since the filter may increase expiratory resistance, spot checks of the pressure (measured at the expiratory limb) can ensure safe application.

High-flow nasal cannula (HFNC) has gained popularity in neonatology as an alternative to CPAP. Limited available data from adults suggest that there is possibly a substantial dispersion of exhaled air with HFNC that increases with liter flow and VT. 61 Extrapolating to neonates would suggest very limited distance of dispersion but no specific data are available.

From the available evidence, endotracheal intubation has consistently been associated with the greatest risk of viral transmission due to the unavoidable short distance between the operator face and patient airways with virus acquisition coming from simple breathing of the patient. 53 Recently, an influenza study confirmed that only bronchoscopy and intubation were significant AGPs. 54 Such information is not available in neonates, nor are there any data regarding surfactant administration either with traditional endotracheal tube (ET) instillation or using less invasive techniques as AGPs. Thus, because of the potential risk of transmission, endotracheal intubation should be performed by skilled providers using full PPE. An appropriately sized ET should be used to avoid excessive leak. 

Infants with suspected or confirmed SARS-CoV-2 infection requiring MV should be placed under isolation precautions. Neonates are usually intubated with uncuffed ET due to risks of upper airway injury. This may lead to leaks around the tube and create aerosol dispersion. However, due to the small VT used, the magnitude of dispersion is likely minor (►Fig. 3). Also, a closed ET suction circuit should be used, and a hydrophobic filter placed at the exhalation port (never between the circuit adapter and ET). There are no clear data to support any specific mode of ventilation to treat viral pneumonia/ARDS in neonates or decrease aerosol dispersion. High-frequency ventilation seems to be safe as investigated in one adult study. 54 However, it should be noted that while with conventional and highfrequency jet ventilation exhaled gases exit via the expiratory limb and therefore can be captured by a filter, during high-frequency oscillatory ventilation with the SensorMedics 3100A or B, the exhaled gases are exhausted directly into the ambient air.

After having witnessed nearly 2 million cases of COVID-19 worldwide, the proportion of neonates with the disease is extremely low. Moreover, neonatal COVID-19 appears to be acquired postnatally and associated with favorable respiratory outcomes. For those reasons, provision of respiratory care in newborn infants should continue in accordance with current standards and major practice changes should be avoided to minimize harm. However, to protect HCW from suspected or confirmed cases of neonatal SARS-CoV-2 infection, it is critical to consistently implement safe respiratory practices including proper patient isolation, optimal PPE, and the use of viral filters to the expiratory limbs of any respiratory device. Lastly, information is changing rapidly, and clinicians should watch frequently for updates as the state of knowledge evolves.

Authors' Contributions W.S. and G.M.S. conceptualized and designed the review, drafted the initial manuscript, and reviewed and revised the manuscript. P.M. and M.K. reviewed the extracted data and analyses of the cases and reviewed and revised the final manuscript including all tables and figures. S.L. conceptualized and designed all figures, participated on several drafts of the manuscript, and reviewed and revised the final manuscript, including all tables. All authors critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

None.

COVID-19 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals

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

Clinical analysis of pregnant women with 2019 novel coronavirus pneumonia

Infants born to mothers with a new coronavirus (COVID-19)

Perinatal transmission of COVID-19 associated SARS-CoV-2: should we worry?

COVID-19 in pregnancy with comorbidities: More liberal testing strategy is needed

An uncomplicated delivery in a patient with COVID-19 in the United States

Management of the newborn with suspected or confirmed SARS-CoV-2 infection

Association of COVID-19 infection with pregnancy outcomes in healthcare workers and general women

Emergency caesarean section on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) confirmed patient

Maternal and neonatal outcomes of pregnant women with COVID-19 pneumonia: a case-control study

Lack of vertical transmission of severe acute respiratory syndrome coronavirus 2

Pregnancy and perinatal outcomes of women with coronavirus disease (COVID-19) pneumonia: a preliminary analysis

Clinical and CT imaging features of the COVID-19 pneumonia: Focus on pregnant women and children

Coronavirus disease 2019 (COVID-19) during pregnancy: a case series

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

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

Neonatal COVID-19 and Respiratory Care Shalish et al

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited

Radiological findings and clinical characteristics of pregnant women with COVID-19 pneumonia

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

A pregnant woman with COVID-19 in Central America

Antibodies in infants born to mothers with COVID-19 pneumonia

Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan, China

Analysis of the pregnancy outcomes in pregnant women with COVID-19 in Hubei Province] (in Chinese)

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 report of neonatal COVID-19 infection in China

Can SARS-CoV-2 infection be acquired in utero? More definite evidence is needed

Characteristics of and important lessons from the Coronavirus Disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention

Coronavirus disease 2019 (COVID-19) in Italy

CDC COVID-19 Response Team. Coronavirus disease in children -United States

A case series of children with 2019 novel coronavirus infection: clinical and epidemiological features

COVID-19 infection in a paucisymptomatic infant: Raising the index of suspicion in epidemic settings

A 55-day-old female infant infected with COVID 19: presenting with pneumonia, liver injury, and heart damage

Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China

A well infant with Coronavirus Disease 2019 (COVID-19) with high viral load

Novel coronavirus in a 15-dayold neonate with clinical signs of sepsis, a case report

The first infant case of COVID-19 acquired from a secondary transmission in Vietnam

Chest computed tomography in children with COVID-19 respiratory infection

SARS-CoV-2 Infection in Children

Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study

The different clinical characteristics of corona virus disease cases between children and their families in China -the character of children with COVID-19

Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China

Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults

-novel coronavirus infection in a three-month-old baby

COVID-19 in children and altered inflammatory responses

What do we know about SARS-CoV-2 infection in neonates and infants? The Neonatal Infectious Diseases Collaborative Group of the Italian Society of Neonatology. SIN Informa Magazine of the Italian Society of Neonatology

The Montreux definition of neonatal ARDS: biological and clinical background behind the description of a new entity

Textbook of Neonatal Resuscitation (NRP)

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

Infection prevention and control of epidemic-and pandemicprone acute respiratory infections in health care

Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review

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

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

Mask ventilation and dispersion of exhaled air

Noninvasive positive-pressure ventilation: An experimental model to assess air and particle dispersion

Non-invasive Mechanical Ventilation: Models to Assess Air and Particle Dispersion. In: Esquinas AM

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

Exhaled air dispersion distances during noninvasive ventilation via different Respironics face masks

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

Neonatal COVID-19 and Respiratory Care Shalish et al

None declared.