CASE REPORT
published: 16 March 2020
doi: 10.3389/fped.2020.00104
Frontiers in Pediatrics | www.frontiersin.org 1 March 2020 | Volume 8 | Article 104
Edited by:
Claus Klingenberg,
Arctic University of Norway, Norway
Reviewed by:
Daniel Cooper Payne,
Centers for Disease Control and
Prevention (CDC), United States
Lars Navér,
Karolinska Institutet (KI), Sweden
*Correspondence:
Yalan Liu
liuyalan0923@hotmail.com
†
These authors have contributed
equally to this work
Specialty section:
This article was submitted to
Neonatology,
a section of the journal
Frontiers in Pediatrics
Received: 13 February 2020
Accepted: 28 February 2020
Published: 16 March 2020
Citation:
Chen Y, Peng H, Wang L, Zhao Y,
Zeng L, Gao H and Liu Y (2020)
Infants Born to Mothers With a New
Coronavirus (COVID-19).
Front. Pediatr. 8:104.
doi: 10.3389/fped.2020.00104
Infants Born to Mothers With a New
Coronavirus (COVID-19)
Yan Chen
1†
, Hua Peng
1†
, Lin Wang
1
, Yin Zhao
2
, Lingkong Zeng
3
, Hui Gao
2
and Yalan Liu
1
*
1
Department of Pediatric, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan,
China,
2
Department of Obstetrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology,
Wuhan, China,
3
Department of Neonatal, Wuhan Children’s Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji
Medical College, Huazhong University of Science and Technology, Wuhan, China
A novel viral respiratory disease caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), is responsible for an epidemic of the coronavirus disease
2019 (COVID-19) in cases in China and worldwide. Four full-term, singleton infants were
born to pregnant women who tested positive for COVID-19 in the city of Wuhan, the
capital of Hubei province, China, where the disease was first identified. Of the three
infants, for who consent to be diagnostically tested was provided, none tested positive for
the virus. None of the infants developed serious clinical symptoms such as fever, cough,
diarrhea, or abnormal radiologic or hematologic evidence, and all four infants were alive
at the time of hospital discharge. Two infants had rashes of unknown etiology at birth, and
one had facial ulcerations. One infant had tachypnea and was supported by non-invasive
mechanical ventilation for 3 days. One had rashes at birth but was discharged without
parental consent for a diagnostic test. This case report describes the clinical course of
four live born infants, born to pregnant women with the COVID-19 infection.
Keywords: newborns, clinical course, China, COVID-19 infected mothers, vertical transmission
INTRODUCTION
The new coronavirus 2019 (COVID-19) is an epidemic in Wuhan and the population is believed to
be immunologically naïve. As the epidemic progresses, there remains little understanding of infant
and childhood COVID-19 infections and their clinical picture. As of 22 February 2020, 77,043
cases of novel COVID-19 infections have been confirmed and 2,445 people have died (http://
2019ncov.chinacdc.cn/2019-nCoV/). During this epidemic, four live-born infa nts were born in
our medical center, to pregnant women with the COVID-19 infection. Three of the four pregnant
women gave birth by cesarean section due to concerns about symptomatic maternal infection. The
other infant was born by vaginal delivery to a mother experiencing fever (highest temperature
38.3
◦
C), with a diagnostically confirmed infection. The most important question is whether the
COVID-19 could be transmitted vertically to the fetus from the pregnant mother and cause a
clinically significant infection. Recently, a finding from nine other cases suggested that there is
no evidence for intrauterine infection caused by vertical transmission in women who develop
COVID-19 pneumonia in late pregnancy (
1). We believe this present report is the second c ase
report on vertical transmission between COVID-19 pre gnant women and their infants. Moreover,
this report will focus more on infants. This case report describes the clinical course of four live born
infants born to pregnant women with the COVID-19 infection.
Chen et al. Newborns of COVID-19 Infected Mothers
CASE REPORT
Cases of the Mothers
All four mothers were symptomatically infe cted with COVID-19
during the 3rd trimester. On admission, the regular symptoms
of pregnant mothers with COVID-19 were fever (three out of
four patients), cough (two out of four patients), myalgia or
fatigue (two out of four patients), and he adache (two out of
four patients). Only one patient felt reduced fetal movement and
one experienced dyspnea. Lymphocytes were below the normal
range (lymphocyte count <1.1 × 10
9
/L) in all patients, and two
patients showed lymphopenia (lymphocyte count <1.0 × 10
9
/L).
Both leucocytes and platelet counts were below the normal range
(white blood cell count <4 × 10
9
/L, platelet count <100× 10
9
/L)
in the mother in Case 4 (shown in Table 1). The mother in
Case 3 developed anemia (hemoglobin 83 g/L) and dyspnea 5
days after being admitted. There was a significant increase of the
level of C-response protein in all pregnant mothers. Coagulation
function and blood biochemistry of all the mothers were
normal. Five respiratory pathogens (Mycoplasma, Chlamydia,
Respiratory syncytial virus, Adenovirus, and Coxsackie virus)
and the nucleic acid of influenza viruses A and B of all patients
were negative (laboratory findings shown in Table 1). An RT-
PCR assay confirmed that the throat swab of the four pregnant
women were positive for COVID-19. Abnormalities in chest
CT images and bilateral involvement were detected among all
pregnant women. A cesarean section was performed for three
patients in the acute phase of the dise ase while one patient
underwent vaginal delivery because of the onset of labor. Four
full-term infants were born. All infants were isolated from their
mother immediately after birth. We des cribe the clinical course of
these four infants (laboratory findings shown in Table 2). Three
mothers of the infants recovered from their COVID-19 infections
and were released 3–5 days after delivery. However, one moth er
suffered severe dyspnea after delivery which required respiratory
support—she did, however, survive. All four infants and their
mothers were healthy upon a post-discharge follow-up.
Cases of the Infants
Three male, and one female infant was born beyond 37 weeks’
gestation and had a birt h weight above 3,000 g. All infants had a 1-
min Apgar score of 7–8 and 5-min Apgar score of 8–9 (Table 2).
They were isolated from their mothers immediately after birth
and received formula feeding. Three of the four infants tested
negative for COVID-19 using a throat swab specimen in RT-PCR
72 h after birth and one baby’s parents did not provide consent
for t h eir baby to be tested for COVID-19.
Two of the four infants were healthy. Two of the four infants
had rashes after birth, however, the rash distribution and shape
differed. The infant in Case 2 had some maculopapules scattered
all over the body, and one facial skin ulceration on the forehead
(size about 0.3 × 0.5 cm
2
). The rash disappeared and skin
desquamation appeared the next day wit hout any treatment. The
rash of the infant in Case 3 was present on the forehead and
seemed to diffuse small miliary red papules on day 2. The rash
disappeared on day 10 without treatment (Table 2). The infant in
Case 2, the mother of whom had cholecystitis, developed edema
TABLE 1 | Clinic and laboratory characteristics of mothers.
Case 1 Case 2 Case 3 Case 4
Age, years 28 34 23 31
Maternal history G1P1 G1P1 G2P1 G2P2
Comorbidity No Cholecystitis Placenta
previa
No
Signs and symptoms
Fever Yes No Yes Yes
Cough Yes No Yes No
Fatigue Yes No No Yes
Headache Yes No No Yes
Mulligrubs No Yes No No
Dyspnea Yes No Yes No
Fetal movement Normal Normal Normal Decrease
Heart rate (per min, at arrival) 117 99 122 137
Laboratory findings
White blood cell count, × 10
9
/L 4.7 6.8 8.3 3.7
Lymphocyte count, × 10
9
/L 1.0 1.1 0.8 0.7
Neutrophil count, × 10
9
/L 3.5 5.3 7.1 2.8
Hemoglobin, g/L 111 123 124 131
Platelet count, × 10
9
/L 218 160 114 92
C-response Protein, mg/L 11 26 51 19
Activated partial thromboplastin
time, s
53.1 40.2 54 37.3
Prothrombin time, s 13.1 11.5 12.6 11.9
D-dimer, mg/L 1.9 2.2 3.0 0.6
FIB 1.5 4.8 4.9 3.8
Albumin, g/L 32.9 30.8 33 33.1
Alanine aminotransferase, U/L 25 21 19 22
Aspartate aminotransferase,
U/L
37 29 27 13
Total bilirubin, mmol/L 10.6 10 16.4 10.8
Creatinine, µmol/L 46.0 44.9 39.9 57.2
Blood urea nitrogen, mmol/L 2.8 2.2 1.5 3.0
Seven respiratory pathogen
@
Neg Neg Neg Neg
@
Seven respiratory pathogen: Mycoplasma, Chlamydia, Respiratory syncytial virus,
Adenovirus, Coxsackie virus, and influenza viruses A/B.
of the late ral thigh on day 3, and the level of serum albumin was
only 26 g/L. The baby was taking full formula feeds on day 4.
The baby was discharged from the NICU (neonatal intensive care
unit) 6 days after birth. The infant in Case 3, the mother of whom
had placenta previa, suffered transient tachypnea of the newborn
(TTN) and required nasal- Continuous Positive Airway Pressure
(nCPAP) after birth. Breathing became regular within 3 days. The
baby was taking full formula feeds on day 5 and was dis charged
from t he NICU on day 7 (Table 2).
DISCUSSION
In this study, four pregnant women were confirmed to have
the COVID-19 infection. One mother experienced reduced fetal
movement. One mother developed anemia and dyspnea after
Frontiers in Pediatrics | www.frontiersin.org 2 March 2020 | Volume 8 | Article 104
Chen et al. Newborns of COVID-19 Infected Mothers
TABLE 2 | Clinic and laboratory characteristics of the newborns.
Case 1 Case 2 Case 3 Case 4
2019-nCoV of father Neg Neg Neg Positive
Sex female male male male
Gestational age, weeks 37
+2
39
+0
37
+3
38
+4
Birth weight, g 3,200 3,050 3,800 3,550
Apgar score (1, 5 min) 8.9 8.9 7.8 8.9
Delivery mode Cesarean Cesarean Cesarean Vaginal
delivery
Laboratory findings
White blood cell count, × 10
9
/L – 13.1 18.7 22.2
Lymphocyte count, × 10
9
/L – 2.6 5.2 2.7
Neutrophil count, × 10
9
/L – 9.0 11.6 7.5
Hemoglobin, g/L – 198 172 175
Platelet count, × 10
9
/L – 217 258 285
C-response protein, mg/L – 1 0 0
Albumin, g/L – 29 35.9 42.6
Alanine aminotransferase, U/L – 6 10 28
Aspartate aminotransferase,
U/L
– 23 41 116
Total bilirubin, mmol/L – 41.7 43.1 80.2
Activated partial thromboplastin
time, s
– 15.5 14.3 13.6
Prothrombin time, s – 50.8 52.3 53
INR – 1.3 1.1 1.1
FIB – 3.7 2.2 1.6
Signs and symptoms
Dyspnea No No Yes No
Oxygen therapy No No Yes No
Heart rate Normal Normal Normal Normal
Blood pressure Normal Normal Normal Normal
Edema No Yes Yes No
Rash No Yes Yes No
Chest radiograph – Normal TTN Normal
2019-nCoV (throat swab) Neg – Neg Neg
admission. Of the three inf ants whose parents provided consent
to be diagnostically tested, none tested positive for the virus.
None of the infants developed serious clinical symptoms such
as fever, cough, or diarrhea. Two newborns had a rash, which
disappeared spontaneously without treatment; one newborn had
mild dyspnea, and was considered to suffer from TTN and
supported by non-invasive mechanical ventilation for 3 days. All
of the four babies are doing well and have been formula feeding
since birt h.
Coronavirus (CoVs) (
2) is an enveloped positive-sense
RNA virus, which infects humans and a wide variety of
animals, causing diseases in the respiratory, enteric, hepatic,
and neurological systems with varying severity (3). In the past
few decades, newly evolved CoVs have posed a global threat
to public health, such as severe acute respiratory syndrome
coronavirus (SARS-CoV) and Middle East respiratory syndrome
coronavirus (MERS-CoV) that were implicated in the 2003
outbreak in Guangdong, China and the 2012 outbreak in the
Middle East, respectively (
2). On 10 January 2020, a new
coronavirus causing a pneumonia epidemic in Wuhan City
in central China was denoted as COVID-19 by the World
Health Organization (WHO) (4). As of 22 February 2020, nearly
77,043 COVID-19 infections in humans have been confirmed in
China, with at least 2,445 reported deaths. As reported herein,
four pregnant women were confirmed to have the COVID-
19 infection in our medical center, which is designated as
one of the treatment centers for pregnant women with the
COVID-19 infection. Importantly, we found neither SARS-CoV-
2 diagnostic positivity nor immediate evidence of symptomatic
COVID-19 among the infants born to the symptomatic,
test-positive mothers.
On the basis of previous reports (
5–7), SARS-CoV and MERS-
CoV were associated with critical maternal illness, spontaneous
abortion, or even maternal death. In these four pregnant women
with the COVID-19 infection, three had fever, two had a cough
and experienced headache. In laboratory data, there was lower
lymphocyte count and higher CRP in blood analysis. Typical
CT images of COVID-19 infection with ground glass changes
were presented in these pregnant patients. These four pregnant
women had no critical maternal illness. Only one of them
experienced reduced fetal movement and one had dyspnea. These
symptoms, at onset of delivery, were similar to other populations
(
8). To prevent COVID-19 intrauterine, perinatal, and postnatal
transmission, three pregnant women received a cesarean section.
One of the three pregnant women suffered placenta previa,
which made it necessary to opt for a cesarean section. Only
one pregnant mother adopted a vaginal delivery because of an
emergency labor process.
Shek et al. (9) reported that perinatal transmission of the
SARS-associated coronavirus was not detected in any of the
five live born infants who were born to pregnant women
with SARS during the community outbreak in Hong Kong
in 2003. In addition, none of the infants developed clinical,
radiologic, hematologic, or biochemical evidence suggestive of
SARS. Consistent with these reports, in our study, RT-PCR assay
confirmed that the throat swab of the three cases were negative
for COVID-19. We regret that the infant in Case 2 did not
have a COVID-19 diagnosis as the baby’s guardian’s did not
provide consent.
Assiri et al. (7) reported five cases of pregnant women infected
with MERS-CoV from Saudi Arabia, and all pregnancies were
in the second or third trimester. Among the five pregnancies,
two pregnant women died during their illnesses, two resulted
in perinatal death (one pregnancy resulted in intrauterine
fetal demise, and one infant died 4 h after an emergency
cesarean delivery). It was reported that 12 pregnant women were
diagnosed to have the SARS infecti on during the outbreak in
Hong Kong (10). Seven mothers presented in the first trimester,
and the rest were in their late second and third trimester. It
was reported that the SARS infection in pregnant women could
lead to severe intrauterine growth retardation, which could be
due to the prolonged usage of high dose systemic corticosteroids
or antiviral agents and/or the impact of a severe maternal
debilitating illness on normal fetal growth (
9, 10). In this study, all
four cases reported on were delivered during the acute phase of
Frontiers in Pediatrics | www.frontiersin.org 3 March 2020 | Volume 8 | Article 104
Chen et al. Newborns of COVID-19 Infected Mothers
the illness, at 37–39 weeks of gestation, and the birth weight of all
the babies were appropriate for their gestational age. Throughout
the clinical course, there were no manifestations or radiologic,
hematologic, or biochemical evidence suggestive of COVID-19
infection. This study is similar to reports of SARS infection
(
9) (Table 2).
Coronaviruses cause respiratory and intestinal infections
in animals and humans (11). For adult patients, the clinical
manifestations of COVID-19 infection include fever, c ough,
shortness of breath, muscle ache, sore throat, diarrhea, and
so on (11). The minority of patients showed severe and even
fatal respiratory diseases such as acute respiratory distress
syndrome. According to imaging examination, most patients
showed bilateral pneumonia, multiple mottling, or ground-glass
opacity. In this study, only the infant in Case 3 showed dyspnea
and required oxygen therapy. A chest radiograph of the infant
in Case 3 showed that the brightness of the left lung was
slightly decreased, and the texture of the right lung was slightly
blurred. His condition was relieved gradually after 3 days of
nCPAP treatment.
It has been confirmed that COVID-19 gravely damages
leucocytes, and could lead to multiple organ d amage along with
the respiratory system (12). In this study, blood assays of the
three infant cases were normal, and all the blood cell counts
and hemoglobin concentrations fluctuated within the normal
reference range. It is worth noting that both Case 2 and Case
3 presented a transient skin rash after birth. Whether this was
attributable to t h e maternal inflammatory toxin effect requires
further study. At follow up, the four newborns were health and
had grown on formula feeding.
This feature reveals that none of the four newborns of the
mothers with COVID-19 developed COVID-19 infection. In this
study, viral nucleic acid detection using real-time polymerase
chain reaction (RT-PCR) remains, is taken as the standard of
COVID-19 infection. A recent retrospective analysis in adults
showed that the sensitivity of RT-PCR i s 71% for COVID-19
infection (
13). Therefore, the reliability of diagnostic testing
should be further evaluated, especially in children. Another
limitation of t h is report was the small number of cases, and
imperfect clinic data. No COVID-19 vertical transmission was
detected. Further studies for viral infection in placenta, amniotic
fluid, neonatal blood, gastric fluid, and anal swab, and the viral
depending receptor on children will be detected in future.
DATA AVAILABILITY STATEMENT
The datasets generated for this study are available on request to
the c orresponding author.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by the Institutional Review Board of Union Hospital,
Huazhong University of Science & Technology. Written
informed consent to participate in this study was provided by
the participants’ legal guardian/next of kin. Written informed
consent was obtained from the individual(s), and minor(s)’ legal
guardian/next of kin, for the publication of any potentially
identifiable images or data included in this article.
AUTHOR CONTRIBUTIONS
YC and HP designed the study, drafted the initial manuscript,
and reviewed and revised the manuscript. LW, HG, YZ, and
LZ designed the data collection instruments, collected the
data, and reviewed and revised the manuscript. YL designed
the study, coordinated, and supervised data collection, and
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.
FUNDING
This study was supported by the National Natural Science
Foundation of China (81500218, 81601 324, and 81300523).
REFERENCES
1. Chen HJ, Guo JJ, Wang C, Luo F, Yu XC, Zhang W, et al. Clinical
characteristics and intrauterine vertical transmission potential of
COVID-19 infection in nine pregnant women:a retrospective review of
medical records. Lancet. (2020) 20:30360–3. doi: 10.101 6/S 0 14 0- 6 73 6(2 0)3
0360-3
2. Phan T. Novel coronavirus: from discovery to clinical diagnostics.
Infect Genet Evol. (2020) 79:104211. doi: 10.1016/j.meegid.2020.1
04211
3. Wong ACP, Li X, Lau SKP, Woo PCY. Global epidemiology of bat
coronaviruses. Viruses. (2019) 11:E174. doi: 1 0.3 39 0/ v110 2 01 74
4. Yu F, Du L, Ojcius DM, Pan C, Jiang S. Measures for diagnosing and
treating infections by a novel coronavirus responsible for a pneumonia
outbreak originating in Wuhan, China. Microbes Infect. (2020) 20:30025–3.
doi: 10.1016/j.micinf.2020.01.003
5. R obertson CA, Lowther SA, Birch T, Tan C, Sorhage F, Stockman L, et al.
SARS and pregnancy: a case report. Emerg Infect Dis. (2004) 10:345–8.
doi: 10.3201/eid1002.030736
6. Wong SF, Chow KM, de Swiet M. Severe acute respiratory syndrome and
pregnancy. BJOG. (2003) 110:641–2. doi: 10.1046/j.147 1- 05 2 8.20 0 3.03 0 08 .x
7. Assiri A, Abedi GR, Al Masri M, Bin Saeed A, Gerber SI, Watson JT.
Middle e ast respiratory syndrome coronavirus infection during pregnancy:
a report of 5 cases from Saudi Arabia. Clin Infect Dis. (2016) 63:951–3.
doi: 10.1093/cid/ciw412
8. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical
features of patients infected with 2019 novel coronavirus in Wuhan,
China. Lancet. (2020) 395: 497–506. doi: 10.1016/S0140-6736(20)3
0183-5
9. Shek CC, Ng PC, Fung GP, Cheng FW, Chan PK, Peiris MJ, et al. Infants
born to mothers with se vere acute respiratory syndrome. Pediatrics. (2003)
112:e254. doi: 10.1542/peds.112.4.e254
10. Wong SF, Chow KM, Leung TN, Ng WF, Ng TK, Shek CC, et al.
Pregnancy and perinatal outcomes of women with severe acute respiratory
syndrome. Am J Obstet Gynecol. (2004) 191:292– 7. doi: 1 0.10 1 6/j .ajog.2003.
11.019
11. Bonilla-Aldana DK, Quintero-Rada K, Montoya-Posada JP, Ramirez S,
Paniz-Mondolfi A, Rabaan A, et al. SARS-CoV, MERS-CoV and now the
Frontiers in Pediatrics | www.frontiersin.org 4 March 2020 | Volume 8 | Article 104
Chen et al. Newborns of COVID-19 Infected Mothers
2019-novel CoV: have we investigated enough about coronaviruses? -
a bibliometric analysis. Travel Med Infect Dis. (2020) 33:101566.
doi: 10.1016/j.tmaid.2020.101566
12. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al.
Epidemiological and clinical characteristics of 99 cases of 2019
novel coronavirus pneumonia in Wuhan, China: a descriptive
study. Lancet. (2020) 395:507–13. doi: 10.1016/S0140-6736(20)3
0211-7
13. Fang Y, Zhang H, Xie J, Lin M, Ying L, Pang P, et al. Sensitivity of chest
CT for COVID-19: comparison to RT-PCR. Radiology. (2020) 19:200432.
doi: 10.1148/radiol.2020200432
Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2020 Chen, Peng, Wang, Zhao, Zeng, Gao and Liu. This is an open-
access article distributed under the terms of the Creative Commons Attribution
License (CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that the
original publication in this journal is cited, in accordance with accepted academic
practice. No use, distribution or reproduction is permitted which does not comply
with these terms.
Frontiers in Pediatrics | www.frontiersin.org 5 March 2020 | Volume 8 | Article 104
