Recommended measures on newborn infants born to mothers with suspected orconfirmed the new coronavirus infection
February 26, 2020 (1st Edition)
February 28, 2020 (2nd Edition)
March 23, 2020 (3rd Edition)
October 19, 2020 (4th Edition) (Major revision)
Japanese Society for Neonatal Health and Development
President: Tomohiko Nakamura
Vaccination and Infection Control Committee
Chairperson: Ichiro Morioka
A new type of coronavirus infection was reported in Wuhan City, Hubei Province, China
in December 2019 and has become a global pandemic. Since then, many scientificfindings have been accumulated. In Japan, the new coronavirus infection is currently
classified as a designated infectious disease and must be managed accordingly. Based on
the current knowledge, this Society has revised the previous recommendation on
newborn infants born to mothers with suspected or confirmed the new coronavirus
infection during the early neonatal period. This recommendation is tentative based on
the current scientific knowledge and under the current situation of the pandemic.
Therefore, this could be revised appropriately in the future.
Several reviews and case series have been published on the vertical transmission to
newborn infants from the new coronavirus-positive mothers [1,2]. The positive rate forthe new coronavirus infection among those newborn infants during the early neonatal
period was reported as 0.0-4.7% [3-18]. In some cases, serological positive tests of IgM
suggesting prenatal infection were reported [4]. However, a trans-placental infection
has been considered rare because of placental structure and immune responses [19,20].
Similarly, prenatal infections with the same coronavirus species as MERS or seasonalcoronavirus have rarely been reported [21]. Therefore, the chance of prenatal infectionof the virus can be extremely low, although it cannot be ruled out. However, a horizontal
infection from positive mothers to their infants could not be preventable without strictmeasures of infection control. Most newborn infants infected have been reported asasymptomatic or mild except in rare cases [5].

<Care of newborn infants immediately after birth>
It is mandatory recommended to prevent the coronavirus transmission to newborn
infants with all available precautions (mainly isolation and prevention of droplet andcontact infections). The followings are necessary measures according to each situation.
1. When an infant was born from the mother who developed symptoms with thecoronavirus infection during labor of who became asymptomatic just before delivery, orfrom the positive mother by a universal screening test just before delivery.
・To prevent droplet and contact transmissions from the mother to the newborn infant,they should be temporarily separated from each other. The mother should be isolated
in a private room. The newborn infant should be isolated in an incubator or undercohort isolation.
・Close observation of the infant is mandatory by monitoring the infant's symptoms andvital signs. If the infant becomes symptomatic, an attending neonatologist should
contact an infectious control team inside a hospital and also report a health center ofthe jurisdiction. At the same time, virologic tests and necessary treatment should beconsidered.
・Once the isolation period of the mother has expired, the direct contact between themother and the newborn infants can be allowed. According to a report in Japan
where all mothers and their infants were separated after birth, the number of
infants infected from the mothers with PCR-positive for the coronavirus has been
extremely limited (as of October 2020). At the moment, it is not conceivable tomitigate this separation policy with concrete evidence, although the disadvantage ofseparation is well recognized.
・If the mother wishes to share a room with the infant, caregivers can consider it under
the condition that the mother and her family can follow and perform the strict
preventive measures through guidance [22-24].
2. When an infant was born from the mother who became positive for the coronavirus
between delivery and her hospital discharge (the dyad was already in close contact
through kangaroo care, breastfeeding, etc.)
・ Once the positive result confirmed, the mother should be isolated inside the hospitalor considered the transfer to a hospital designated for infectious diseases.
・ The infant should be isolated as a close contact person and examined for thecoronavirus using a PCR test.
・If the test for the infant is positive, the isolation of the dyad in a seme room can beacceptable. If the test is negative, the infant should be closely monitored as a close
contact person.
3. Isolation of the newborn infant・The newborn infant with the coronavirus infection or suspected should be isolated in anegative pressure room or private room. If not available, the infant could be placed in
an incubator with at least 2m intervals between each incubator [24]. Alternatively, it
could be also allowed to keep the infant in a cot with a cohort at 2m intervals.
・Healthcare workers in contact with the infant should wear gowns, surgical masks, faceshields or goggles, in addition to hand hygiene before and after the procedure. If theinfant is treated with a nasal oxygen cannula of 2 L/ min or more or NCPAP/NHFC,
an N95 mask instead of a surgical mask should be used instead [24].
・The infants should be tested for the coronavirus twice within 24 hours after birth andafter 48 hours [23,24]. To confirm the negative result, two separate tests aremandatory, because infants with negative results immediately after birth could
become positive later in several reports [23]. However, in special circumstances, asingle test during 24-48 hours after birth could be acceptable [23]. A nasopharyngeal
swab examination using a nucleic acid amplification method with PCR or LAMP is
recommended.
・ If the negative result is confirmed finally, the isolation of the infant is not mandatory
furthermore even before discharge. On the other hand, if the test is positive, it isadvisable to repeat the tests at intervals of 48-72 hours until two consecutive tests
show negative [24].
4. Breastfeeding and handling of breast milk [18, 26, 27]
・ At this time (as of October 2020), the risk of viral transmission through breastfeedingfrom coronavirus positive mothers is considered to be extremely low. If we considered
the beneficial effects of breastfeeding such as the specific immune substances inbreast milk from infected mothers, which may act to prevent the coronavirus
infection, there is no clear evidence to stop breastfeeding uniformly.
・There are two methods for continuing breastfeeding; (1) use of expressed breastmilk
and (2) direct breastfeeding.
(1) When the expressed breastmilk is selected, it should be noted that most of theviral infection occurs through contaminated breastmilk pumping equipment or
containers rather than breastmilk itself. Therefore, the complete sterilization of
those materials is essential to prevent the infection.

(2) When direct breastfeeding is selected, there is a risk of infection from the mother tothe infant through droplet or contact infection. Therefore, the mother must washand sanitize their hands and wear a mask before breastfeeding.
・Regarding the method of isolation for coronavirus-positive mother and her newborn
infant, it is still largely dependent on the rule at each hospital. Therefore, it may be
inevitable to select bottle feeding according to the local condition at each hospital
having a lack of spacing and stuffing, even if the mother wishes to breastfeed. In thiscase, continuous support such as milking of breastmilk would be rather important tostart direct breastfeeding once their isolation is no more needed.
5. Coronavirus PCR screening for all pregnant mothers [18,28-30]
・The positive rate for the coronavirus test among pregnant women in outbreak areas of
the infections was ranged between 3.8-15.4%, although 66-100% of them wereasymptomatic.
・Because pregnant women usually require long-term care in person during labor anddelivery inside hospitals, it is recommended to test for the coronavirus infection
before admission routinely. In this way, risks of healthcare workers and newborn
infants to be infected by pregnant women could be reduced through appropriate
personal protective measures.
・On the other hand, there is no guideline so far to recommend a pre-hospital universal
screening for the coronavirus infection positively. There may be a concern to increase
the rate of cesarean delivery more than usual and the number of newborn infants
necessary to be hospitalized in the NICU.
・Because the pre-hospital universal screening for the coronavirus infection among
pregnant women in Japan is not a mandatory test at present, this concept may vary
greatly depending on the region and facility. Furthermore, since the accuracy of thosetests is so limited, each judicial region and hospital should decide their practicalrules of the timing of the screening test and the patient flow after. Furthermore, thisinformation should be shared among all staff responsible in each region and hospital.

Q&A
1. I understand that in principle, the mother cannot enter the NICU until she isdiagnosed not to have a risk of coronavirus transmission, but what about the father?
At that time, how to get information about an infant’s condition and how to proceedwith informed consent? Also, when all my family members need isolation at home,our infant can stay at the hospital as long as needed?
A: Since the family members living together are identified as close contact persons, allfamilies cannot be allowed to visit and to enter the NICU during the incubation
period of the virus (14 days after the final contact). Appropriate explanations about
the medical condition of the infant and informed consent can be provided to theparents by telephone or online devices. Alternatively, we think family members who
do not live together and do not have contact history (for example, grandparents) canmeet medical staff in person. In case, the infant will be discharged to the parent’s
home, the infant must stay to stay in the hospital until the risk of infection fromparents is reduced enough. If that is difficult, the infant can discharge to the home ofrelatives (for example, grandparents) who have no contact history with the parents.
Otherwise, we can consult with a healthcare center or a child guidance center.
2. Can infection control measures to the infant change depends on delivery mode?
A: At present, the newborn infant should be treated as a close contact person regardlessof delivery mode, cesarean section or vaginal delivery [31].
3. Is there any effect on the newborn infant if the mother is infected with thecoronavirus in the first or second trimester of pregnancy?
A: If mothers who tested positive at early or mid-pregnancy became negative insubsequent tests and finally gave birth at term, there was no report of birth defects
in the infants and no report to detect the virus in the infants [4, 20, 32-36].
References
1. KulkarniR,RajputU, DawreR, et al. Early-onset symptomatic neonatal COVID-19
infection with high probability of verticaltransmission.Infection. 2020.
doi:10.1007/s15010-020-01493-6
2. Oncel MY,Akın IM, KanburogluMK, et al.Amulticenter study on epidemiological andclinical characteristics of 125 newborns born to women infected with COVID-19 by
Turkish Neonatal Society [published online 2020Aug 10]. EurJ Pediatr. 2020; 1-10.
3. HuangW,ZhaoZ, HeZ, et al. Unfavorable outcomes in pregnant patients with
COVID-19.[publishedonline, 2020Aug].JInfect.
4. KotlyarA, GrechukhinaO, ChenA, et al. VerticalTransmission of COVID-19:A
SystematicReview andMeta-analysis[published online 2020 Jul 30].Am JObstet
Gynecol. 2020; S0002-9378(20)3082
5. Sheth S, Shah N, Bhandari V. Outcomes in COVID-19 Positive Neonates andPossibility of Viral Vertical Transmission:ANarrativeReview [publishedonline 31
Jul 2020].Am J Perinatol. 2020; 10.
6. Salvatore CM, Han JY,Acker KP, et al.Neonatal management andoutcomes during
the COVID-19 pandemic: an observation cohort study [publishedonline, 2020 Jul
23]. Lancet ChildAdolesc Health. doi:10.1016/S2352-4642(20)30235-2
7. Antoun L, Taweel NE,Ahmed I et al.Maternal COVID-19 infection,clinicalcharacteristics, pregnancy, and neonatal outcome:Aprospective cohort study[publishedonline, 2020 Jul 15]. EurJObstet GynecolReprod Biol.
8. DenizM, Tezer H. Verticaltransmission of SARS CoV-2: a systematic review.
[publishedonline, 2020 Jul 21]. Matern Fetal Neonatal Med.
9. Marín GabrielMA, Cuadrado I,Álvarez Fernández B, et al.Multi-centre Spanish
study found no incidences of viraltransmission in infants born to mothers with
COVID-19 [published online 2020 Jul 10].Acta Paediatr.2020;10.1111/apa.15474.
10. Zhang L, Dong L,Ming L, et al. Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)infection during late pregnancy: a report of 18patients fromWuhan,
China. BMC Pregnancy Childbirth. 2020; 20 (1): 394. Published 2020 Jul 8
11. Masmejan S, Pomar L, Favre G, et al. Verticaltransmission and materno-fetal
outcomes in 13 patients withCOVID-19 [published online, 2020 Jul 8]. Clin
Microbiol Infect. 2020; S1198-743X(20)30381-5.
12. NayakAH, Kapote DS, FonsecaM, et al.Impact ofthe Coronavirus Infection in
Pregnancy:APreliminary Study of 141Patients.JObstet GynaecolIndia. 2020; 70(4):256-261.
13. Trocado V, Silvestre-Machado J,Azevedo L, et al. Pregnancy and COVID-19: asystematic review of maternal, obstetric and neonatal outcomes [publishedonline,
2020 Jul 7].JMatern Fetal NeonatalMed. 2020; 1-13.
14. AshrafMA, Keshavarz P, Hosseinpour P, et al. Coronavirus Disease 2019
(COVID-19):ASystematicReview of Pregnancy andthe Possibility of Vertical
Transmission. JReprod Infertil. 2020; 21(3): 157-168.
15. Yan J, Guo J, Fan C, et al. Coronavirus disease 2019 in pregnant women: a reportbasedon 116 cases.[published online, 2020 Jul].Am JObstet Gynecol.
16. Fassett MJ, Lurvey LD,YasumuraL, et al. Universal SARS-Cov-2 Screening in
WomenAdmitted for Delivery in a Large Managed CareOrganization [published
2020 Jul 3].Am J Perinatol
17. Sahin D, TanacanA, Erol SA, et al.Apandemic center's experience of managing
pregnant women withCOVID-19 infection in Turkey:Aprospective cohort study. Int
J Gynaecol Obstet. 2020 Jul 18.

18. Rozycki HJ, Kotecha S. Covid-19 in pregnant women and babies:What pediatriciansneedto know. PaediatricRespiratoryReviews. 2020; 35: 31-37
19. Kreis NN,RitterA, Louwen F,Yuan J.AMessage fromthe Human Placenta:
Structural andImmunomodulatory Defense against SARS-CoV-2. Cells. 2020; 9(8):E1777.
20. Schwartz DA, Morotti D, Beigi B, Moshfegh F, Zafaranloo N, Patanè L. Confirming
Vertical Fetal Infection with COVID-19: Neonatal and Pathology Criteria for Early
Onset and Transplacental Transmission of SARS-CoV-2 from Infected Pregnant
Mothers.Arch Pathol LabMed. 2020 Jul 23.
21. Rodríguez-Blanco N, Vegara-Lopez I,Aleo-Giner L, Tuells J.Revisión exploratoria
sobre series de casos de coronavirus (SARS-CoV,MERS-CoV ySARS-CoV-2) y sus
resultados obstétricos y neonatales [Scopingreview of coronavirus case series(SARS-CoV,MERS-CoV and SARS-CoV-2) andtheir obstetric and neonatalresults][publishedonline, 2020 Jul 20].Rev Esp Quimioter. 2020;rodriguez20jul2020.
22. World Health Organization. Clinical management of COVID-19: interimguidance,
27May 2020
https://www.who.int/publications-detail/clinical-management-of-severe-acute-respi
r atory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
23. CDC Covid-19Response Team. Evaluation and Management Considerations for
Neonates atRisk for COVID-19 (Updated Aug. 3, 2020).
https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-newborns.html.
24. American Academy of Pediatrics. Clinical Guidance / Newborn Care:Guidance forthe care of infants whose mothers have suspected or confirmed COVID-19:FAQs:
Management of Infants Born to Mothers with Suspected or Confirmed COVID-19.
LastUpdated 09/10/2020
https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/faqs-m
anagement-of-infants-born-to-covid-19-mothers/
25. Demirjian A, Singh C, Tebruegge M, et al. Probable Vertical Transmission
ofSARS-CoV-2 Infection [publishedonline 2020 Jul 10]. PediatrInfect Dis J. 2020.
26. 母乳育児支援連絡協議会. 新型コロナウイルス感染症（COVID-19）流行時におけ る
乳児栄養、心理的支援に関する提言 〜お母さん、ご家族を支援する方々へ〜
27. Lackey KA et al. SARS-CoV-2 and human milk: Whatis the evidence? Matern Child
Nutr. 2020 May 30: e13032.
28. Universal COVID-19 testing in the obstetric population: impacts on public health.
Cad Saude Publica 2020; 36 (8): e00164820
29. Prabhu M, et al. Pregnancy and postpartum outcomes in a universally tested

population for SARS-CoV-2 in New York City:Aprospective cohort study. BJOG.
2020 Jul 7:10.1111/1471-0528.16403.
30. Martínez-Perez O, Vouga M, Melguizo SC, et al.Association Between Mode ofDeliveryAmong Pregnant Women With COVID-19 and Maternal and Neonatal
Outcomes in Spain. JAMA2020 Jun 8.
31. Wang L, et al. Chinese expert consensus on the perinatal and neonatalmanagementfor the prevention and control ofthe 2019 novel coronavirus infection(First edition). Ann Transl Med. 2020; 8 (3): 47.
32. Prochaska E, Jang M, Burd I. COVID-19 in pregnancy: Placental and neonatal
involvement.Am J Reprod Immunol. 2020 Jul 17: e13306.
33. Bahadur G, Homburg R, Yoong W, Singh C, Bhat M, Kotabagi P,Acharya S, Huirne J,
Doreski PA, Łukaszuk M, MuneerA.Adverse outcomes in SAR-CoV-2 (COVID-19)
and SARS virus related pregnancies with probable vertical transmission.
JBRAAssist Reprod. 2020 Jul 14; 24(3): 351-357.
34. MahyuddinAP, KannegantiA, Wong J, Dimri PS, Su LL, BiswasA, Illanes SE,
Mattar C, Huang RJ, Choolani M. Mechanisms and evidence of verticaltransmission of infections in pregnancy including SARS-CoV-2. Prenat Diagn. 2020
Jun 12:10.1002/pd.5765.
35. Schwartz DA, DhaliwalA. Infections in Pregnancy With COVID-19 and Other
Respiratory RNAVirus DiseasesAre Rarely, If Ever, Transmitted to the Fetus:
Experiences With Coronaviruses, Parainfluenza, Metapneumovirus Respiratory
Syncytial Virus, and Influenza.Arch Pathol Lab Med. 2020Apr 27.
36. Algeri P, Stagnati V, et al. Considerations on COVID-19 pregnancy: a cases series
during outbreak in Bergamo Province, North Italy. J Matern Fetal Neonatal Med.
2020.

Note: This document is published in Japanese and is translated in English personallyfor your convenience, not officially approved.