De Rose et al. Italian Journal of Pediatrics
https://doi.org/10.1186/s13052-020-0820-x(2020) 46:56

REVIEW

Open Access

Novel Coronavirus disease (COVID-19) innewborns and infants: what we know so far
Domenico Umberto De Rose1, Fiammetta Piersigilli1,2, Maria Paola Ronchetti1, Alessandra Santisi1, Iliana Bersani1,
Andrea Dotta1, Olivier Danhaive2, Cinzia Auriti1* and The Study Group of Neonatal Infectious Diseases of The
Italian Society of Neonatology (SIN)

Abstract
Recently, an outbreak of viral pneumonitis in Wuhan, Hubei, China successively spread as a global pandemia, led tothe identification of a novel betacoronavirus species, the 2019 novel coronavirus, successively designated 2019nCoV then SARS-CoV-2). The SARS-CoV-2 causes a clinical syndrome designated coronavirus disease 2019 (COVID19)
with a spectrum of manifestations ranging from mild upper respiratory tract infection to severe pneumonitis, acuterespiratory distress syndrome (ARDS) and death. Few cases have been observed in children and adolescents who
seem to have a more favorable clinical course than other age groups, and even fewer in newborn babies. This
review provides an overview of the knowledge on SARS-CoV-2 epidemiology, transmission, the associated clinicalpresentation and outcomes in newborns and infants up to 6 months of life.
Keywords: Newborns, COVID-19, Infants, SARS-CoV-2, Coronavirus

Introduction
Six coronavirus species were known so far to cause humandisease, four of which (229E, OC43, NL63, and HKU1) typically cause cold symptoms in immunocompetent subjects[1]; the remaining two (Severe acute respiratory syndrome
coronavirus – SARS-CoV – and Middle East respiratory
syndrome coronavirus – MERS-CoV –) are zoonotic in origin and have been identified as causal agents of severe respiratory disease outbreaks from cross-species infections[2]. In December 2019, a cluster of patients with severe
pneumonia of unknown etiology, epidemiologically linked
to a seafood wholesale market in Wuhan (Hubei Province,
China) led to the discovery of a novel, previously unknown
coronavirus, initially designated 2019-nCoV: this agent represents the seventh member of the coronaviridae family
that has the potential to infect humans [3]. Since its emergence in Wuhan, despite strong restrictions to limit* Correspondence: cinzia.auriti@opbg.net
1
Neonatal Intensive Care Unit, Department of Neonatology, Bambino GesùChildren’s Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy
Full list of author information is available at the end of the article

domestic people circulation, the 2019-nCoV infection has
rapidly spread across China and all over the world. Thishighly contagious and deadly virus was subsequently
named Severe Acute Respiratory Syndrome Coronavirus 2(SARS-CoV-2) [4] and the related disease “Coronavirus
Disease 2019” (COVID-19) [5]. On March 11th 2020,
COVID-19 was pronounced as pandemic by World HealthOrganization (WHO) [6]. As of April 7, 2020, the numberof confirmed cases was 1.250.000 worldwide (more than180 countries involved), with 69.210 deaths resulting in a
crude fatality rate of 5.5% at time of writing [7].
All age groups are susceptible, but people with comorbidities or the elderly are more likely to develop a severe
form of the disease. Although children seem to have lesssevere clinical symptoms when infected [8], the potential
harm of this novel disease remains largely unknown in neonates, especially in preterm infants. In the largest pediatricpopulation-based study to date with 2143 cases, over 90%
ranged from asymptomatic to moderate. However, the proportion of severe and critical cases was 10.6% under 1 yearof age, compared to 7.3, 4.2, 4.1 and 3.0% among the 1–5,

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De Rose et al. Italian Journal of Pediatrics(2020) 46:56

6–10, 11–15 and > 15 year subsets, suggesting that infants
may be at higher risk of severe respiratory failure than initially thought [9]. This review provides an overview of thecurrent knowledge of this new pandemic viral infection inthis fragile population.

Methods
The literature search for this article was primarily Internet based, using PubMed and Google. A list of searchterms and phrases was compiled to focus on the general
topics of ‘neonates’ or ‘newborns’ and ‘COVID-19’ or‘2019-nCoV’ or ‘SARS-CoV-2’, without imposing restrictions on date or year, locations, study design, study aim,
or inclusion/exclusion criteria. We reviewed all the articles published till April 07th, 2020. Studies not written
in English or Italian were withdrawn.
SARS, coronaviruses and children

SARS-CoV-2 is a positive-sense, single-stranded RNA
virus, belonging to the genus betacoronavirus, with a
88–96% sequence identity to three bat-derived SARSlikecoronaviruses(bat-SL-CoVZC45,
bat-SLCoVZXC21, RaTG13) and to a coronavirus strains isolated in pangolins -a scaly, ant-eating mammal highly
trafficked for its presumed medicinal virtues and clandestinely sold in live animal markets such as Wuhanwhich possesses the same six key residues of the angiotensin converting enzyme 2 (ACE2) receptor binding domain as SARS-CoV-2 (see below). Neither bat- norpangolin-coronaviruses sampled thus far have the polybasic sites characterizing SARS-CoV-2, and none haveenough similarity to qualify as its direct progenitor, but
the diversity of coronaviruses in animal species is largely
undersampled and scarsely explored [10]). Thus, SARSCoV-2 might have acquired its genomic features by evolutionary mutation in an animal reservoir and passed tohuman from droppings, contaminated food material orother in the market or surrounding regions of Wuhan.
Alternatively, a more distant progenitor of SARS-CoV-2
might have passed to human and gradually acquired its
pathogenic features through adaptation during successive, undetected human-to-human transmissions.
Severe acute respiratory syndromes associated with coronaviruses seem to have a children-sparing pattern, as
suggested by the available literature on SARS-CoV (2003)
and MERS-CoV (2012) epidemics [11–13]. Stockman
et al. reported that children and adolescents are susceptible to SARS-associated coronavirus infection, although
the clinical course and outcome are more favourable inchildren younger than 12 years of age compared with adolescents and adults: in fact no deaths were reported amongchildren with SARS [11, 12]. Bartenfeld et al. reported thatthe only two fatal paediatric MERS-CoV cases had severe

Page 2 of 8

comorbidities (infantile nephrotic syndrome and cystic fibrosis) [13].
SARS- CoV-2 has a stronger transmission capacity
than the former two, but the child-sparing trend seems
to be similar, based on the data analysis regarding theearly transmission dynamics of SARS-CoV-2 (December
2019–January 2020) on the first 425 confirmed cases in
Wuhan: there were no severe cases in children below 15
years of age [14]. In the largest COVID-19 case series todate in mainland China (72,314 cases, updated throughFebruary 11, 2020), 416 cases (1%) had less than 10
years, but the incidence in neonates was not reported:
however, no deaths occurred in this age group, while theoverall case-fatality rate (CFR) was 2.3% [15].
The reason why children are less susceptible to
COVID19 than adults remains unclear [16]. Children are
not generally protected from viral infections, which instead are very frequent from infancy onwards. Otto et al.
showed that children who had received combined diphtheria, pertussis, tetanus, HiB and poliomyelitis vaccination within the third month of life had significantly less
symptomatic infections than those with delayed or partial immunizations, maybe because of an vaccinationassociated unspecific enhancement of immunological activity (e.g. interleukin 2 mediated) or other factors still
unknown [17]. A thorough understanding of the virushost innate interactions during common respiratory infections of childhood (coronaviruses, rhinoviruses,,pneumoviruses (respiratory syncytial virus, metapneumovirus) and ortho/paramyxoviruses (influenza, parainfluenza), all characterized by an RNA genome, will bepivotal to understand these findings [18].
Another hypothesis involves the angiotensin-converting
enzyme 2 (ACE2), a membrane-bound aminopeptidase
highly expressed in lung alveolar epithelial cells and enterocytes of the small intestine, that plays a vital role in the
cardiovascular and immune systems. ACE2 represents amajor gateway to the SARS-CoV-2 infection, although thespecific mechanisms are still uncertain. As with other coronaviruses, the N-terminal portion (S1, receptor binding
domain) of the viral spike (S) glycoprotein binds withhigh-affinity to receptor(s) on the surface of susceptible
cells. Although ACE2 has been identified as a viral receptor, there might be other receptors or co-receptors for thisvirus yet to be discovered [19]. It is possible that ACE2 tissue distribution differs between adults and children andthe maturity and function (e.g., binding ability) of ACE2
in children may be lower than that in adults [9].
Moreover, children’s immune system is still developing: they are probably not yet able to start a cytokine
storm similar to the adult one [20].
Furthermore, we cannot exclude that paediatric SARSCoV-2 infections are often unrecognized or underestimated, as they may remain asymptomatic or manifest

De Rose et al. Italian Journal of Pediatrics(2020) 46:56

with mild, nonspecific symptoms such as hypo reactivity,
headache, cough, nasal congestion, runny nose, and expectoration. Most children have only moderate to lowgrade fever, or even none. Smaller infants can present
primarily with gastrointestinal symptoms such as diarrhoea, abdominal distension and food aversion [21].
A subset of children presents with a mild respiratory
failure, with hypoxia and increased respiratory rate unresponsive to standard oxygen therapy and requiring highflow nasal cannulae or mask. Based on reported cases,
most of these children belong to family clusters, andmostly of them have a benign course, usually recovering
1–2 weeks after disease onset. Newborns, in particular if
preterm, need a more close and cautious observation,
because they are more likely to present with insidiousand non-specific symptoms as lethargy and even dehydration [3, 8, 9].

Diagnosis

Human-to-human SARS-CoV-2 transmission has been
demonstrated from subjects with or without clinicalsymptoms [22]. Transmission mainly occurs via droplets[14] but can also be through skin contact [23], faecal-oraltransmission [24], and ocular surface contact [25]. The
virus can be detected by Real Time Polymerase Chain Reaction (RT-PCR) in bronchoalveolar-lavage fluid [3], sputum [26], saliva [27] and, in particular, in nasopharyngeal
swabs which are the gold standard for diagnosis [27]. The
incubation period of COVID ranges from 2 to 14 days,
though most cases declare between 3 and 7 days [8].
On laboratory examinations, leukopenia and lymphocytopenia are typical, while C-reactive protein and procalcitonin
are usually within normal values. Other findings may
include mild thrombocytopenia, and increased creatine kinase, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase [28].
Pulmonary lesions are shown more clearly by chest CT
scan than X-ray examination; common findings include
ground-glass opacity, multiple bilateral lobular and segmental consolidations, in particular in the peripheral lung [20].
Testing all admitted infants with respiratory symptoms
for SARS-CoV-2 could represent a wrongful use of resources, since neonatal respiratory failure can result
from a wide range of causes [29].
Infants should be suspected of SARS-CoV-2 if they are[28]:a) related with a cluster outbreak or exposed torelatives infected with SARS-CoV-2 (including family members, medical staff and visitors);b) delivered by suspected or confirmed SARS-CoV-2
infected mothers between 14 days before delivery
and 28 days after delivery;

Page 3 of 8c) showing lymphocytopenia or typical chest imaging
findings.
Maternal-foetal transmission and breastfeeding

Whether transmission can occur through mother–infantvertically or breast milk has not been clearly establishedyet. In a recent research letter, Dong et al. [30] speculate
the possibility of the maternal fetal transmission of thevirus. In a term infant, from mother with SARS-CoV-2
pneumonia from the 34th week of pregnancy, they foundvirus-specific IgG and IgM, high levels of Interleukin 6
and 10, negative nasopharyngeal swab and no symptoms,
since 2 h from the delivery to the following 3 weeks.
The authors conclude that despite uncertainty, so highIgM levels at 2 h of life would suggest an intrauterine infection. However, as Kimberlin and Stagno [31] commented, maternal-fetal transmission of the virus ispossible, as its nucleic acid has been found in blood
samples, but the only finding of specific IgM in the newborn is not enough and the probability of a false positivity is high.
There is currently no evidence showing vertical transmission and intrauterine SARS-CoV-2 infection in foetuses of women developing COVID-19 pneumonia inlate pregnancy. Table 1 summarizes clinical characteristics of the cases described in literature to date [33–38],
although data are available only on a small sample size.
We included also an unpublished case of a preterm infant born to a mother with COVID-19, in Bruxelles,
Belgium.
We cannot definitively state whether caesarean section
could prevent transmission from a pregnant mother with
COVID-19 pneumonia more than vaginal delivery, because data are lacking.
However, maternal hypoxemia and fever caused by severe infection can lead to fetal distress, premature delivery
and other risks [39]. Therefore, a detailed morphology
scan at 18–24 weeks of gestation is indicated for pregnant
women with suspected, probable or confirmed COVID-19
infection [40].
On February 6th, 2020, a neonate born by emergency
caesarean section to a woman with COVID-19 pneumonia
tested positive for SARS-CoV-2 infection 36 h after birth[32]. His mother had developed fever and was suspected
to have COVID-19 pneumonia based on typical chest CT
scan findings upon admission. The neonatal throat swab
was obtained approximately 30 h after birth, thus providing no direct evidence for intrauterine infection.
The Belgian preterm infant included in Table 1 resulted positive for SARS-CoV-2 infection as well, but thepharyngeal swab was performed only at 6 days of life,
after the finding of a viral pneumonia in mother.
Very recently Zeng et al. [38] reported a series of 33
infants from mothers with COVID-19: three of whom

De Rose et al. Italian Journal of Pediatrics(2020) 46:56

Page 4 of 8

Table 1 Clinical features of neonates born to mothers with perinatal confirmed SARS-CoV-2 infection
All

Dong
Chen
Li
Wang
Zhu et al.
et al. [30] et al. [32] et al. et al. [34] [35]
[33]

Chen
et al.
[36]

Liu
et al.
[37]

Zeng
et al.
[38]

Piersigilli et al.
(unpublished)

Pregnant women

69

1

9

1

1

9 (1 was amother oftwins)

4

10

33

1

Caesarean section

53/69(76.8%)

1

9/9

1

1

7/9

3/4

10/10

26/33 1

Positive maternal test (SARS-CoV-2 68/69(98.6%)
quantitative RT-PCR on samples
from the respiratory tract)

1

9/9

1

1

8/9 *

4/4

10/10

33/33 1

Median maternal age, years(range)30 (22–40)

29

28 (26–
40)

30

28

30 (25–35)

29.5(23–34)

30.5
(22–
36)

NA

37

Median gestational age (GA)on admission, weeks (range)

36 (26–39)

38

37 (36–
39)

35

30

34 (31–39)

37.5(37–39)

35.5
(32–
38)

NA

26

Median onset of maternal
symptoms to delivery, days
(range)2.5 (0–26)

26

3 (1–7)2

6

2.5 (0–6)

NA

NA

NA

Maternal fever on admission

37/69(53.6%)

1

7/9

1

1

8/10

3/4

8/10

8/33

0

Newborns

70

1

9

1

1

10

4

10

33

1

Positive cord blood samples

0

0 **

0/6

0

0

NA

NA

NA

NA

NA

Positive neonatal throat swab
samples

4/63 tested

0 **

0/6

0

0

0/9;1 nottested0/3; 1nottested

0/10

3/33

1

Positive breastmilk samples

0

0

0/6

0

0

0/9; 1 nottested0/3; 1nottested

0/10

NA

0

2

Low birthweight (< 2500 g)

14/70 (20%)

0

2/9

NA

1

7/10

0

NA

3/33

1

Premature delivery

24/70(34.3%)

0

4/9

1

1

6/10

1

6/10

4/33

1

Intrauterine foetal distress

15/69(22%) + 1
stillbirth

0

0

1

6/10

1/4

3/10 + 1
stillbirth

0

2/33

2/9

Premature rupture of membranes

6/70 (8.6%)

0

2/9

0

0

3/10

0

1/10

3/33

0

NA not available*The local CDC registered the mother of a couple of twins as a confirmed SARS-CoV-2 because of viral interstitial pneumonia at chest CT scan although RT-PCR
returned negative**In the newborn reported by Dong et al.,they found virus-specific IgG and IgM, high levels of Interleukin 6 and 10, negative nasopharyngeal swab and nosymptoms, since two hours from the delivery to the following three weeks

were symptomatic (one preterm with a gestational age –GA – of 31 weeks), with a radiological picture of pneumonia. Nasopharyngeal and rectal swab test yielded
positive for SARS-CoV-2 virus. These infants presented
a clinical course worse than the other ones described todate. The outcome was however favorable, with the test
negativity at 6th and 7th days after the onset of symptoms in two infants and in the third, respectively. The
31 weeks neonate developed coagulopathy, associatedwith Enterobacter sepsis, which resolved with the recovery of sepsis. None of the newborn babies died.
No cord blood, amniotic fluid or placenta tests were
performed, so whether the COVID-19 infection was acquire by intrauterine transmission or postnatally cannot

be determined in these cases. Nevertheless, these fivecases call for special protection measures in order toprevent postnatal infections in neonates born to motherswith COVID-19 pneumonia.
The eventuality of the vertical transmission of SARSCoV-2 through breast milk could not be confirmed. Only
limited data on SARS-CoV-2 excretion in breast milk areavailable: Chen et al. reported that all breast milk samples
from 9 mothers with COVID-19 pneumonia were negative[32]. This is the reason why most neonatal guidelines do
not recommend against breastfeeding from mothers with
COVID-19. Nevertheless, specific precautions have to betaken, such as wearing a mask during breastfeeding andobserving meticulous hand hygiene.

De Rose et al. Italian Journal of Pediatrics(2020) 46:56

Clinical features in newborns and infants

Clinical features of infected newborns, especially preterm
infants, might be non-specific and include acute respiratory distress syndrome, temperature instability, gastrointestinal and cardiovascular dysfunction. All infants
with suspected COVID-19 should be isolated and monitored, whether symptomatic or not [41].
In the cohort described by Zhu et al. [35], nine of ten
neonates born to mothers with confirmed COVID-19
presented with shortness of breath (n = 6), cyanosis (n =3), vomiting and feeding intolerance (n = 2), fever (n = 2),increased heart rate (n = 1), moaning and rashes (n = 3).
Two of these newborns had thrombocytopenia accompanied by abnormal liver function. One of them died (amale with a GA of 34 + 5 weeks and a birthweight of
2200 g) because of gastric bleeding and shock resulting
in multiple organ failure and disseminated intravascular
coagulation despite blood transfusions and supportive
treatment. Another patient (a female with a GA of 34 +6 weeks and a birthweight of 2300 g) presented withgastrointestinal haemorrhage and disseminated intravascular coagulation but responded to gamma globulin
intravenous administration and survived. Notably, noneof these neonates tested positive for SARS-CoV-2.
In the cohort reported by Chen et al. [36] three of thefour infants tested negative for SARS-CoV-2 using athroat swab specimen and one couldn’t be tested becauseof parental refusal: two of the four infants were healthy.
Two of the four infants had rashes after birth, however,
the rash distribution and shape differed (respectively,
some maculopapules scattered all over the body and small
military red papules on the forehead). One infant had mild
post-natal dyspnea diagnosed as transient tachypnea of
the newborn (TTN); he required just nasal-Continuous
Positive Airway Pressure (nCPAP) for 3 days.
In the cohort described by Zeng et al. [38], among
three positive newborns, the preterm neonate (GA 31
weeks) required mechanical ventilation.
No symptomatic neonates born to mothers with confirmed COVID-19 were described by Chen [32], Li [33]and Wang [34].
Li et al. compared clinical characteristics, maternal
and neonatal outcomes of pregnant women with orwithout COVID-19 pneumonia: COVID-19 infection
was not found in the newborns and none developed severe neonatal complications [42].
Clinical features of infants up to 6 months of life withconfirmed postnatal SARS-CoV-2 infection reported inliterature until now [43, 44] were summarized in Table 2:
all were hospitalized but none required intensive care.
The infant described by Kam et al. was brought to hospital for clinical assessment and isolation considering his
close contact with confirmed COVID-19 cases, but
remained asymptomatic [44].

Page 5 of 8

The first three newborns with COVID-19 (age: 17days, 5 days, 30 days), reported in a short review by Lu
et al. [45] were not included in this table because described in Chinese: they all presented with shortness ofbreath, milk intolerance and fever; their vital signs werestable and symptoms were mild.
Newspapers reported other cases of infants with
COVID-19 in Northern Italy in March 2020 without
need for intensive care; they were not included in thetable as they were not yet reported in the medical
literature.
Infection control and treatment

When handling suspected or confirmed infected mothers,
the delivery room or operating room should be speciallyprepared, preferably with negative pressure when available[46]; physicians should wear adequate personal protective
equipment (PPE). If the newborn is asymptomatic after
birth and the suspected mother’s test is negative for
SARS-CoV-2, the newborn can room in with the mother;
if the maternal nasal swab is positive for SARS-CoV-2 andmaternal quarantine is required, strict droplet/contact
precautions are required. Many guidelines recommend
the newborn to be isolated in a designated COVID-19
neonatology unit until cleared, although some allow
rooming-in in mother’s room with due infection control
measures (such as 2-m distance from cot to bed and droplet/contact precautions while breastfeeding). A SARSCoV-2 test should be performed after birth: all probableor laboratory-confirmed newborns with SARS-CoV-2
should be isolated or cohorted in a single room (if possible) for at least 14 days. The quarantine room should beequipped with an isolated air cycle system and, given
SARS-CoV-2 high infectivity, negative pressure isolation
rooms are recommended, albeit rarely available [41].
Standard and additional infection control measures shouldbe implemented immediately [47], such as visitor restriction policies and protected pathways.
If a newborn develops COVID-19 manifestations during the isolation period or is highly suspected of SARSCoV-2 infection from admission, the patient should be
immediately directed to a Neonatal Intensive Care Unit
(NICU) of a reference hospital or to a designated
COVID-19 pediatric unit.
Triage procedures should be implemented, as it is important to reserve NICU beds for patients who are inlife-threatening situations [29], and an indiscriminate
NICU admission policy might lead to mistakes in epidemiological data and overestimation of the severity ofthe disease in this category.
In case of neonatal transport, the transport incubatorand the ambulance should be extensively disinfected
after the transfer; strict droplet/contact precautions andisolation should be applied throughout the transport.

De Rose et al. Italian Journal of Pediatrics(2020) 46:56

Page 6 of 8

Table 2 Clinical features of infants with a confirmed COVID-19
Patient

1

Reported in:

Wei et al.
[43]

2

3

4

5

Age

1 month 26 days

3 months

3 months 22days

6months6 months

Sex

FemaleFemaleFemaleMale

Male

Country

China

China

China

China

Singapore

Symptoms at onset

Runny nose;
cough

Cough; sputum
production

Fever

NA

None

Time between admission and diagnosis (days)

1

1

1

2

NA

Epidemiologic history: no. of family members
infected

2

2

1

1

3

Linkage to Wuhan

Yes

Yes

NA

No

Yes

Mechanical ventilation

No

No

No

No

No

Severe complications

No

No

No

No

No

Kam et al.
[44]*NA not available

General management requires a strict continuous
monitoring (heart rate, respiratory rate, oxygen saturation, temperature, blood pressure, blood glucose, andgastrointestinal symptoms), blood examinations and achest X-ray. If necessary respiratory support should bedelivered via High-flow nasal cannula (HFNC), noninvasive ventilation or mechanical ventilation. Antibiotics should be prescribed only to patients with probableor confirmed bacterial infection; empirical use should be
avoided. Surfactant replacement therapy, inhaled nitricoxide (iNO), and high-frequency oscillatory ventilation(HFOV) might be effective for newborns with severe
acute respiratory distress syndrome but no evidencebased data exist. The question of antenatal corticosteroids for induction of foetal lung maturation in COVID19 -positive or -suspected mothers with preterm laboror predicted preterm delivery is controversial, since
there is strong evidence that their use prevents deathand improve long-term outcomes across the range ofprematurity [48]; conversely, corticosteroids have shownno proven benefit and/or potential harm in other similar
viral infections such as SARS, MERS, RSV and influenza[49]. In the absence of uniform guidelines to date, therisk/benefit ratio should be carefully weighed on an individual basis and take informed parental choices into account. For all procedures that may produce aerosols on
suspected or confirmed infants, airborne precautions
should be taken. In critically ill neonates, continuous
renal replacement (CRRT) or extracorporeal membrane
oxygenation (ECMO) could become necessary.
There are no data on effective antiviral drugs (ie remdesivir or lopinavir/ritonavir) and anti-cytokine storm (ietocilizumab) for children with COVID-19 to date.
Intravenous immunoglobulin can be used in severecases when indicated (1 g/kg/day for 2 days, or 400 mg/

kg/day for 5 days), but its efficacy needs further evaluation [8].
Newborns could be discharged after resolution of respiratory symptoms, lack of fever for at least 3–5 days,
and after two nasal swabs negative for SARS-CoV-2
taken at least 48 h apart [47].
As maternal separation may cause anxiety and maternal depression, psychological comfort should be offeredto the parents [40].

Conclusions
To our best knowledge, this review is the largest to datedescribing clinical features of SARS-CoV-2 infection inneonates and infants up to 6 months of age. Although
we still do not know how massively SARS-CoV-2 will
spread around the world and affect the populationworldwide, the initial data reported in children so far are
reassuring. However, due to the limited number of casesand clinical evidence, pediatricians should continually
update their knowledge and be aware of the risks in particular in the high-risk population of newborn and preterm infants.
Abbreviations
ACE2: Angiotensin converting enzyme 2; ARDS: Acute respiratory distresssyndrome; CFR: Case-fatality rate; COVID19: Coronavirus disease 2019;
CRRT: Continuous renal replacement; nCPAP: Nasal-Continuous Positive
Airway Pressure; ECMO: Extracorporeal membrane oxygenation;
GA: Gestational age; HFNC: High-flow nasal cannula; HFOV: High-frequency
oscillatory ventilation; MERS-CoV: Middle East respiratory syndrome
coronavirus; NICU: Neonatal Intensive Care Unit; iNO: Inhaled nitric oxide;
PPE: Personal protective equipment; RSV: Respiratory Syncitial Virus; RTPCR: Real Time Polymerase Chain Reaction; SARS-CoV: Severe acuterespiratory syndrome coronavirus; TTN: Transient tachypnea of the newborn;
WHO: World Health Organization

De Rose et al. Italian Journal of Pediatrics(2020) 46:56

Acknowledgements
We would like to thank the Neonatal Infectivology Study Group of the Italian
Neonatology Society (SIN) for the constant support to cultural updating
activities.
Authors’ contributions
All authors have been involved in writing the manuscript. The author(s) readand approved the final manuscript.
Funding
None.
Availability of data and materials
The literature search for this article was primarily Internet based, using
PubMed and Google.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors have no conflict of interest to declare.
Author details
1
Neonatal Intensive Care Unit, Department of Neonatology, Bambino GesùChildren’s Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy. 2Division of
Neonatology, St-Luc University Hospital, Catholic University of Louvain, 1200
Brussels, Belgium.
Received: 24 March 2020 Accepted: 17 April 2020

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