We review the manifestations of the SARS-CoV-2 virus in newborns. We are joined by Kikelomo Babata, MD, Assistant Professor of Neonatal-Perinatal Medicine at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern Newborn Nursery.
Dr. Neeta Goli:
Welcome back to the podcast. Today, we will review neonatal manifestations of the SARS-CoV-2 virus. We are recording remotely due to the ongoing COVID pandemic. We are joined today by Dr. Kikelomo Babata, a neonatologist and Assistant Professor of Neonatal-Perinatal Medicine at UT Southwestern. Dr. Babata's work on COVID includes providing talks to the UT Southwestern Division of Neonatal–Perinatal Medicine, providing a regional talk to multiple healthcare stakeholders in the State of Texas via the North Central Texas Trauma Regional Advisory Council, writing a review on COVID in the newborn for the Greater Pediatric Society of Dallas newsletter, and developing and publishing a protocol for Cochrane database of systematic reviews to understand the safety of breastfeeding and other infant feeding strategies during the COVID-19 pandemic. Dr. Babata, thanks for joining us today.
Dr. Kikelomo Babata:
Thank you for having me.
Dr. Neeta Goli:
This severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2 virus, which causes the coronavirus disease 2019, or COVID-19, has at the time of this taping, led to over 58 million cases and 1.3 million deaths worldwide, and 12 million cases and over a quarter million deaths in the US alone. This episode is being recorded in late November of 2020. Guidelines and recommendations may change over time. The terms used to describe the virus and disease process as SARS-CoV-2, COVID-19 or simply COVID, may be used interchangeably. In our last episode, we discussed perinatal exposure to the SARS-CoV-2 virus and potential effects on the fetus and neonate. Today, we will discuss manifestations in neonates who are themselves found to be infected by the virus. For infants born to mothers infected by the SARS-CoV-2 virus, how common is transmission of the virus from mom to baby, either vertical or horizontal?
Dr. Kikelomo Babata:
Thank you for that question. That's a very good question and a question I know that is on the minds of a lot of us. So of the overwhelming numbers we have been seeing overall, and this is worldwide, really consistently across multiple databases, whether it's the databases from China, from New York, or even from our own published reports, about 2 to 3% is the rate of transmission that we are seeing. And that's the numbers that we are seeing consistently, of 2 to 3% of mothers who have the infection in about the seven days before birth end up having babies who are infected.
Dr. Neeta Goli:
And if a baby is found to be infected with the virus, how do we determine whether the infection was transmitted prenatally, perinatally during the birth process, or postnatally?
Dr. Kikelomo Babata:
So part of what we can do for that is the timing. It can be very hard to determine for certain. There was a Nature Reviews paper that has looked at over 176 infants who have been infected with COVID-19, with the SARS-CoV-2 virus, and what they have reported is up to about 70% of the cases are acquired postnatally, so more than 72 hours after birth. And they are reporting about 30%, most likely vertical transmission. So definitely we do the test at 24 to 48 hours to help decide if this is a vertical transmission versus a postnatal infection. Other things that have been done have been testing of the placenta, testing of the cord blood, testing of the amniotic fluid. But I think what is most suggestive of a vertical transmission is if the placenta tests positive. So there have been studies that have been done that have found either specific histologic changes, or actually have been able to isolate the SARS-CoV-2 virus in the placenta. In those situations you can say, with definite certainty, that it was a vertical transmission.
Dr. Neeta Goli:
And what manifestations of SARS-CoV-2 have we seen in affected neonates?
Dr. Kikelomo Babata:
The majority of infants are asymptomatic or have mild symptoms. Of those who have symptoms, about half of them would have a fever, and fever and respiratory symptoms are the most common symptoms. So we are seeing tachypnea, grunting, intercostal retractions, some x-ray changes. We also are seeing some GI, gastrointestinal symptoms, as well. So like vomiting, poor feeding things like that, loose stool. We're also seeing neurologic symptoms like hypotonia, apnea, lethargy. There have been some rare cases of hemodynamic instability, or some kids who have hypotension or tachycardia, and actually need to have pressors. But those are the exceptions. For the most part, most babies have mild symptoms.
Dr. Neeta Goli:
Is this at all related to prematurity?
Dr. Kikelomo Babata:
Some of them. Some of the symptoms that we've seen is related to prematurity. But some for instance, if you think about a lot of the infants that are actually reported in the literature, some of the infants reported in the literature with most significant symptoms are actually some of those who have been discharged home. So for instance, they're all who have been discharged home, or just come from home essentially.
Dr. Kikelomo Babata:
Like for instance, there was a case in the literature, which was published I think in Houston, of a baby who presented in the emergency room with fever, hypotension, the baby ended up needing to be intubated, had a pneumothorax, had pretty significant lung symptoms. Now that's an extreme. And that's really the only case I've read where the baby has got that sick. So in that situation, it was definitely most likely due to the virus as opposed to prematurity or in some of our premature infants. It can be difficult to say for certain, if the symptoms are due to the virus or prematurity. The babies that we have taken care of who have been positive in our own system really have not had any symptoms that have been out of the ordinary for what you'd expect for their gestational age.
Dr. Neeta Goli:
What special precautions do we take for infants who are found to be positive for the virus?
Dr. Kikelomo Babata:
So, for the infants who are positive for the virus, I think the biggest thing is we take the precautions even before the results come back. So, we wear adequate PPE, which includes the mask, we wear goggles, we wear a gown, we keep the baby... If the baby, for some reason needs to be in the NICU, the baby is in the isolation room. If the baby is bedside with mom, we recommend she do all these things. Babies overall not have a significant amount of aerosolization if they're not on CPAP or a nasal cannula. However, things that need to be kept in mind, very important thing that needs to be kept in mind for babies is the risk of fecal shedding. Because babies can actually shed the virus in their stool for a prolonged period of time. So while they're in the hospital, as well as when they go home, their parents need to be aware of taking special precautions in handling the babies' stool.
Dr. Neeta Goli:
How long do we expect them to shed the virus in the stool?
Dr. Kikelomo Babata:
I have read reports of up to a month, so I know that that might be the exception, but if I were advising a parent, I would say at least for the next six weeks to be extra careful as they handle the stool.
Dr. Neeta Goli:
And then did these babies need any additional follow-up or monitoring after hospital discharge?
Dr. Kikelomo Babata:
So usually what we have done, and this has been done in other studies as well, is usually a telehealth visits, so other than their regular pediatrician visits, physicians have been checking in with babies to see how they have been doing. For the most part, most of these babies are very well, I really have not read many reports of babies needing to be readmitted in the hospital. We will need long-term developmental follow-ups to get a sense of, does this have any developmental effects for the babies? Right now we are still early in the pandemic, but I would expect that we will start to see reports of outcomes at six months, 12 months, 18 months, the periods when we do our routine developmental surveillance.
Dr. Neeta Goli:
Do we have any longer-term outcome data on these babies?
Dr. Kikelomo Babata:
Yeah. So this is still evolving, because we're still so early in the pandemic. So it is kind of, we don't have any long-term data other than, on the knowing for sure how babies have done after they've been discharged from the hospital, whether they go sick or not. But definitely long-term developmental surveillance is something that we need to continue to do to get a better sense of, is this a virus like Zika, where you worry about the risk of developmental delays in the baby, or not.
Dr. Neeta Goli:
For those of us who are taking care of these babies in the nursery who are then found to be positive, how do you recommend we counsel the parents?
Dr. Kikelomo Babata:
Well, I think the most important thing, really, if the baby is positive, the risk of transmission from the baby to the parents or the healthcare workers is relatively low fsrom the baby’ secretions. So like if the baby is crying, the nasal secretions or things like that have to be considered to be highly infectious. The truth is most babies who test positive, usually in a couple of days they will end up testing negative. But the parents need to make sure they wear a mask, need to make sure they wash their hands often. Need to make sure if they are breastfeeding, we definitely would recommend they continue breastfeeding because they can provide the baby with antibodies that hopefully should keep them healthy, and also make sure that they provide education to other members of the family. So that's what I would say. And when they get discharged home, if for some reason the baby starts to feed less or is less active, if they have any concerns, we definitely want to be advising the parents to call the pediatrician
Dr. Neeta Goli:
And then to end the episode today, what is your favorite part of your workday?
Dr. Kikelomo Babata:
Well, the favorite part of my workday is part of what you've actually made me do, just kind of, I really enjoy digging deep into the literature, finding answers to questions, finding new discoveries, like some of what I enjoyed doing most in these last 24 hours is just the breast milk, seeing that maybe in the future, the antibodies in breast milk can actually be used for respiratory illnesses. I know that's kind of far-fetched but the fact that that thought is even there. So just the excitement from digging deep into the literature and finding answers to questions is the most exciting part of my workday.
Dr. Neeta Goli:
Thanks again for joining us today, Dr. Babata.
Dr. Kikelomo Babata:
Thank you Dr. Goli.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests, and do not necessarily reflect the views of the university.