A single-center observational study on clinical features and outcomes of 21 SARS-CoV-2-infected neonates from India

Long-Term Growth and Neurodevelopmental Outcomes of Neonates Infected with SARS-CoV-2 during the COVID-19 Pandemic at 18-24 Months Corrected Age: A Prospective Observational Study

INTRODUCTION

During the early coronavirus disease (COVID-19) pandemic in 2020, researchers cautioned about the potential neuroinvasive capability of the virus and long-term neurological consequences. Although a few preliminary studies have found delayed communication, fine motor, and problem-solving skills in infants after COVID-19 infection, there continues to be a paucity of data on long-term development of neonates diagnosed with COVID-19.

METHODS

We conducted a prospective study of 20 neonates who acquired severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection during the first wave of the pandemic (April-July 2020). At 18-24 months corrected age, we assessed neurodevelopment by Bayley Scales of Infant and Toddler Development, the third edition (BSID-III), along with growth, hearing, and vision evaluation.

RESULTS

The mean corrected age at assessment was 21 months 11 days ± 1 month 28 days. We found developmental delay in nearly half of the children with scores below one standard deviation in either of the BSID-III domains. Mild delay in either motor, cognitive, or language domains was found in 9 (45%) children and moderate delay in 2 (10%). Expressive language, fine motor, and receptive language were predominantly affected. None of the children had hearing impairment, blindness, or significant growth faltering including clinically severe microcephaly. The mean composite cognitive, language, and motor scores were significantly lower in those with neurodevelopmental delay (p value - 0.02, 0.000, and 0.03, respectively) without any differences in their disease characteristics.

CONCLUSION

Neonates infected with SARS-CoV-2 have an increased risk of developmental delays in expressive language, fine motor, and receptive language skills at 18-24 months of age. The severity of delays is predominantly mild.

Implementing recommended breastfeeding practices in healthcare facilities in India during the COVID-19 pandemic: a scoping review of health system bottlenecks and potential solutions

Background

Breastfeeding practices in institutional settings got disrupted during the COVID-19 pandemic. We reviewed the challenges faced and the "work-around" solutions identified for implementing recommended breastfeeding practices in institutionalized mother-newborn dyads in resource constrained settings during the pandemic with the aim to identify learnings that could be potentially adapted to the Indian and relatable contexts, for building resilient health systems.

Methods

We conducted a scoping review of literature using the PRISMA ScR Extension guidelines. We searched the Medline via PubMed and Web of Science databases for literature published between 1st December 2019 and 15th April 2022. We included original research, reviews, and policy recommendations published in English language and on India while others were excluded. Further, we searched for relevant gray literature on Google (free word search), websites of government and major professional bodies in India. Three reviewers independently conducted screening and data extraction and the results were displayed in tabular form. Challenges and potential solutions for breastfeeding were identified and were categorized under one or more suitable headings based on the WHO building blocks for health systems.

Results

We extracted data from 28 papers that were deemed eligible. Challenges were identified across all the six building blocks. Lack of standard guidelines for crisis management, separation of the newborn from the mother immediately after birth, inadequate logistics and resources for infection prevention and control, limited health workforce, extensive use of formula and alternative foods, inconsistent quality of care and breastfeeding support, poor awareness among beneficiaries about breastfeeding practices (and especially, about its safety during the pandemic) were some of the challenges identified. The solutions primarily focused on the development of standard guidelines and operating procedures, restricted use of formula, use of telemedicine services for counseling and awareness and improving resource availability for risk mitigation through strategic mobilization.

Conclusion

The COVID-19 pandemic has provided rich learning opportunities for health system strengthening in India. Countries must strengthen learning mechanisms to identify and adapt best practices from within their health systems and from other relatable settings.

COVID-19 Disease in Under-5 Children: Current Status and Strategies for Prevention including Vaccination

Since the coronavirus disease (COVID-19) pandemic hit the globe in early 2020, we have steadily gained insight into its pathogenesis; thereby improving surveillance and preventive measures. In contrast to other respiratory viruses, neonates and young children infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) have a milder clinical presentation, with only a small proportion needing hospitalization and intensive care support. With the emergence of novel variants and improved testing services, there has been a higher incidence of COVID-19 disease reported among children and neonates. Despite this, the proportion of young children with severe disease has not increased. Key mechanisms that protect young children from severe COVID-19 disease include the placental barrier, differential expression of angiotensin-converting enzyme 2 (ACE-2) receptors, immature immune response, and passive transfer of antibodies via placenta and human milk. Implementing mass vaccination programs has been a major milestone in reducing the global disease burden. However, considering the lower risk of severe COVID-19 illness in young children and the limited evidence about long-term vaccine safety, the risk-benefit balance in children under five years of age is more complex. In this review, we do not support or undermine vaccination of young children but outline current evidence and guidelines, and highlight controversies, knowledge gaps, and ethical issues related to COVID-19 vaccination in young children. Regulatory bodies should consider the individual and community benefits of vaccinating younger children in their local epidemiological setting while planning regional immunization policies.

Clinical Outcomes of COVID-19 in Newborns and Infants: A Multicenter Experience of 576 Cases

BACKGROUND

The literature describing clinical presentation, disease course and outcomes of SARS-COV-2 in infants remains scarce.

METHODS

We conducted a retrospective study across 2 major pediatric referral centers evaluating the demographics, clinical and laboratory characteristics, management and outcomes of COVID-19 among newborns and infants in the United Arab Emirates (UAE). Clinical and biochemical markers were evaluated for their accuracy in predicting intensive care unit (ICU) transfer and death.

RESULTS

A total of 576 COVID-19-positive infants were evaluated with a mean age of 164 days. The mean duration of symptoms was 1.48 days. Fever was present in 36.5% of the cohort, while 44.3% had nasal congestion. Eight infants (out of 575; 1.39%) required transfer to the ICU for impending respiratory failure and 2 required invasive ventilation. Symptomatic (fever, nasal congestion) infants were not more likely to be transferred to the ICU (chi-squared test, P = 0.77). ICU transfer was associated with a higher chance of receiving antibiotics (70.6% vs 35.4%; chi-squared test, P = 0.003). On multivariate analysis, none of the clinical parameters (age, symptoms, laboratory tests) predicted transfer to the ICU. No deaths were reported during the observation period.

CONCLUSIONS

Infants with SARS-COV-2 infection have a benign clinical course with favorable outcomes. Less than 2% require ICU transfer. Clinical vigilance is required as none of the admission parameters predicted ICU transfer.

A systematic review and meta-analysis of otorhinolaryngological manifestations of coronavirus disease 2019 in paediatric patients

BACKGROUND

This meta-analysis provides a quantitative measure of the otorhinolaryngological manifestations of coronavirus disease 2019 in children.

METHODS

A structured literature review was carried out using PubMed, Embase and Cochrane Central, employing pertinent search terms. The statistical analysis was performed using Stata version 14.2 software, and the analysed data were expressed as the pooled prevalence of the symptoms with 95 per cent confidence intervals.

RESULTS

The commonest symptoms noted were cough (38 per cent (95 per cent confidence interval = 33-42; I² = 97.5 per cent)), sore throat (12 per cent (95 per cent confidence interval =10-14; I² = 93.7 per cent)), and nasal discharge (15 per cent (95 per cent confidence interval = 12-19; I² = 96.9 per cent)). Anosmia and taste disturbances showed a pooled prevalence of 8 per cent each. Hearing loss, vertigo and hoarseness were rarely reported.

CONCLUSION

Cough, sore throat and nasal discharge were the commonest otorhinolaryngological symptoms in paediatric patients with coronavirus disease 2019. Compared with adults, anosmia and taste disturbances were infrequently reported in children.

An observational study for appraisal of clinical outcome and risk of mother-to-child SARS-CoV-2 transmission in neonates provided the benefits of mothers' own milk

This observational study done during April-December 2020 at a tertiary-care hospital in Haryana (India) enrolled 152 SARS-CoV-2-exposed neonates. Among them, 150 neonates had perinatal SARS-CoV-2 exposure and 2 neonates had late postnatal exposure. Stable infant-mother dyads were roomed-in with precautions to support breastfeeding. Nasopharyngeal swabs collected from neonates were tested for SARS-CoV-2 by reverse transcriptase-polymerase chain reaction (RT-PCR) test. There was a high incidence of prematurity (23%), low birth weight (31%), intrauterine fetal distress (16%), perinatal asphyxia (6%), admission to neonatal intensive care unit (24%), and mortality (1.3%) among neonates with perinatal SARS-CoV-2 exposure. In this sub-group, 20 neonates tested positive for SARS-CoV-2 in nasopharyngeal swab sample(s). A recent official publication by the World Health Organization emphasizes that the perinatal SARS-CoV-2-exposed neonates found RT-PCR positive once in upper respiratory (non-sterile) sample must document viral persistence in another non-sterile sample for confirmation of mother-to-child virus transmission. With this approach, only one neonate was confirmed intrapartum transmission. A telephonic follow-up in discharged neonates at 1 month of age or 1 month postexposure recorded them all to be asymptomatic and doing well.Conclusion: Neonates with perinatal SARS-CoV-2 exposure constitute a high-risk group and it is not uncommon to get a positive RT-PCR report in upper respiratory sample(s) from these babies. Majority of them do not demonstrate viral persistence. Clinical outcomes are favorable in breastfed infants roomed-in with their asymptomatic-mild symptomatic SARS-CoV-2-infected mothers following appropriate safety protocols. What is Known: •Neonates with perinatal exposure suffer a high burden of morbidities and mortality. •Still, an uncertainty exists about rooming-in and breastfeeding among neonates born to SARS-CoV-2 positive mothers. What is New: •With the policy of mother-infant rooming-in and supporting breastfeeding, none of the neonate suffered clinical illness compatible with postnatal SARS-CoV-2 transmission and infection. •Around 13% perinatal exposed neonates demonstrated SARS-CoV-2 RNA in nasopharyngeal swab samples but the majority of them did not demonstrate viral persistence.

Clinical characteristics & outcome of SARS-CoV-2 infected neonates presenting to paediatric emergency

Background & objectives

Data on neonatal COVID-19 are limited to the immediate postnatal period, with a primary focus on vertical transmission in inborn infants. This study was aimed to assess the characteristics and outcome of COVID-19 in outborn neonates.

Methods

All neonates admitted to the paediatric emergency from August 1 to December 31, 2020, were included in the study. SARS-CoV-2 reverse transcription- (RT)-PCR test was done on oro/nasopharyngeal specimens obtained at admission. The clinical characteristics and outcomes of SARS-CoV-2 positive and negative neonates were compared and the diagnostic accuracy of a selective testing policy was assessed.

Results

A total of 1225 neonates were admitted during the study period, of whom SARS-CoV-2 RT-PCR was performed in 969. The RT-PCR test was positive in 17 (1.8%). Mean (standard deviation) gestation and birth weight of SARS-CoV-2-infected neonates were 35.5 (3.2) wk and 2274 (695) g, respectively. Most neonates (11/17) with confirmed COVID-19 reported in the first two weeks of life. Respiratory distress (14/17) was the predominant manifestation. Five (5/17, 29.4%) SARS-CoV-2 infected neonates died. Neonates with COVID-19 were at a higher risk for all-cause mortality [odds ratio (OR): 3.1; 95% confidence interval (CI): 1.1-8.9, P=0.03]; however, mortality did not differ after adjusting for lethal malformation (OR: 2.4; 95% CI: 0.7-8.7). Sensitivity, specificity, accuracy, positive and negative likelihood ratios (95% CI) of selective testing policy for SARS-CoV-2 infection at admission was 52.9 (28.5-76.1), 83.3 (80.7-85.6), 82.8 (80.3-85.1), 3.17 (1.98-5.07), and 0.56 (0.34-0.93) per cent, respectively.

Interpretation & conclusions

SARS-CoV-2 positivity rate among the outborn neonates reporting to the paediatric emergency and tested for COVID-19 was observed to be low. The selective testing policy had poor diagnostic accuracy in distinguishing COVID-19 from non-COVID illness.

Outcomes of Neonates Born to Mothers With Coronavirus Disease 2019 (COVID-19) — National Neonatology Forum (NNF) India COVID-19 Registry

Background

Limited evidence exists on perinatal transmission and outcomes of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in neonates.

Objective

To describe clinical outcomes and risk factors for transmission in neonates born to mothers with perinatal SARS-CoV-2 infection.

Design

Prospective cohort of suspected and confirmed SARS-CoV-2 infected neonates entered in National Neonatology Forum (NNF) of India registry.

Subjects

Neonates born to women with SARS-CoV-2 infection within two weeks before or two days after birth and neonates with SARS-CoV-2 infection.

Outcomes

Incidence and risk factors of perinatal transmission.

Results

Among 1713 neonates, SARS-CoV-2 infection status was available for 1330 intramural and 104 extramural neonates. SARS-CoV-2 positivity was reported in 144 intramural and 39 extramural neonates. Perinatal transmission occurred in 106 (8%) and horizontal transmission in 21 (1.5%) intramural neonates. Neonates roomed-in with mother had higher transmission risk (RR1.16, 95% CI 1.1 to 2.4; P=0.01). No association was noted with the mode of delivery or type of feeding. The majority of neonates positive for SARS-CoV2 were asymptomatic. Intramural SARS-CoV-2 positive neonates were more likely to be symptomatic (RR 5, 95%CI 3.3 to 7.7; P<0.0001) and need resuscitation (RR 2, 95%CI 1.0 to 3.9; P=0.05) compared to SARS-CoV-2 negative neonates. Amongst symptomatic neonates, most morbidities were related to prematurity and perinatal events.

Conclusion

Data from a large cohort suggests perinatal transmission of SARS-CoV-2 infection and increased morbidity in infected infants.