Recommended measures to a new type of coronavirus infection in newborn infants
February 26, 2020 (1st Edition)
February 28, 2020 (2nd Edition)
March 23, 2020(3rd Edition)
Japanese Society for Neonatal Health and Development
President: Tomohiko Nakamura
Vaccination and Infection Control Committee
Chairperson: Ichiro Morioka
The following points have been revised in this edition.
1. At this moment, the prevalence of intrauterine infection to newborn infants is very
low or negligible.
2. Since asymptomatic newborn infants infected with the coronavirus have beenreported and the indication of the viral test has been changed accordingly. All newborn
infants should be subject to virus detection tests regardless of their symptoms.
3. Q&A section consisting of 6 items was added.
4. Some parts of the context and references were updated.

A new type of coronavirus infection was reported in Wuhan City, Hubei Province, China
in December 2019 and now a major epidemic of the infection was noted worldwide. The
number of patients reported in Japan has also been increasing. As of March 23, 2020,
there have been no reports in Japan yet on newborn infants born from mothers infectedwith the coronavirus. However, it would be needed to prepare for those infants. Basedon current knowledge, we have created a plan to respond to newborn infants under acurrent condition.
As of February 2020, no newborn infants infected intrauterine has been reported among
9 infants born from mothers with the coronavirus infection1). However, the othernewborn infants born from mothers with the coronavirus pneumonia without obvious
intrauterine infection have shown fetal distress, preterm delivery, respiratory disorder,
thrombocytopenia, DIC, etc. including a neonatal death, although the causal
relationship has not been clarified2,3). However, no further reports have supported theintrauterine infection positively3-6). These conditions are similar to newborn infants

born from mothers with MARS7). At the moment, the detailed information on perinatal
and neonatal care to cope with the coronavirus infection is limited8). Therefore, thisrecommendation is tentative based on current knowledge and may be revised according
to new scientific evidence.
Please also refer to a Q&A section added in this edition.
<Management of newborn infants immediately after birth>
It is still unclear whether newborn infants could show severe illness when contractedwith the coronavirus compare to other age populations. However, it is mandatory
recommended to prevent coronavirus transmission to newborn infants with all available
precautions including isolation of the infants to prevent droplet and contact
transmissions4, 9-11).
1. If an infant was born from the mother who developed symptoms with the coronavirus
infection during labor or who became asymptomatic 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 ina private room. The newborn infant should be isolated in an incubator or preferably in anegative pressure room. If not available, the infants should be under cohort isolation
using partitions with enough space between infants. All healthcare workers should
provide care or treatment to the infants wearing a face mask and taking adequate
precautions to prevent droplet and contact transmissions.
・If the mother wishes to share a room with the infant, caregivers can consider itthrough an appropriate and sufficient explanation to the mother and her family.
・Close observation of the infant is mandatory by monitoring the infant's symptoms andvital signs. At the same time, an attending neonatologist should contact an infectious
control team inside a hospital and contact a health center of the jurisdiction to consider
virologic tests. If necessary, symptomatic treatment should be also started (commentson respiratory disorder among newborn infants reported in reference12), and symptoms,
examinations, and treatment for children described in reference 13)).
2. If an infant was born from the mother who developed symptoms with the coronavirus
infection between delivery and hospital discharge and the dyad was in close contact
through kangaroo care, breastfeeding, etc.
・The infant and mother should be isolated in the same single room, preferably anegative pressure room, with precautions to prevent droplet and contact transmissions.

Furthermore, it is also preferable to put the infant inside an incubator.to prevent directcontact between the infant and the mother.
・If the close contact between the infant and the mother exists for a sufficient period andthe possibility of the coronavirus transmission is considered high, it is recommended totransfer the infant to a facility that can provide close observation and intensive care forthe infant considering the infection established.
(Comments on respiratory disorder among newborn infants reported in reference12),and symptoms, examinations, and treatment for children described in reference 13)).
・Where the infant transferred, isolation using incubator or cohorts with 2m distancefrom other infants should be in place. Alternatively, an isolation inside a negative
pressure room is more desirable. Furthermore, an attending neonatologist should
contact an infectious control team inside a hospital and contact a health center of thejurisdiction to consider virologic tests. If necessary, symptomatic treatment should bealso started. All healthcare workers should provide care or treatment to the infants
wearing a face mask and taking adequate precautions to prevent droplet and contact
transmissions.
3. If a preterm infant was born from the mother who developed symptoms with thecoronavirus infection during labor or who became asymptomatic just before delivery.
・The infant should be isolated in a negative pressure room inside NICU as mostpreterm infants are already admitted to NICU. If a negative pressure room is notavailable, the infant should be isolated in an incubator with a distance of 2m from otherinfants. If even an incubator is not available, a cohorting with a distance of 2m fromother infants can be applicable.
・Close observation of the infant is mandatory by monitoring the infant's symptoms andvital signs. At the same time, an attending neonatologist should contact an infectious
control team inside a hospital and contact a health center of the jurisdiction to consider
virologic tests. If necessary, symptomatic treatment should be also started. All
healthcare workers should provide care or treatment to the infants wearing a face mask
and taking adequate precautions to prevent droplet and contact transmissions.
・In principle, the mother should not be allowed to enter the NICU until the risk ofinfection from herself reduced. Once the entering is permitted, the mother needs
sufficient precautions to prevent droplet and contact transmission to other infants andstaff in NICU.
The length of isolation or hospitalization should be determined considering risks ofinfection from family members after discharging home.
4. Breastfeeding
During the active infection of the mother, there is a risk of droplet and contact
transmissions of the coronavirus. Therefore, breastfeeding is not recommended.
However, expressed breast milk feeding is encouraged.
The Japan Society of Pediatrics has stated that if the mother already alleviated a feverand clinical conditions are stable, breast milk can be expressed manually after washing
her hands carefully and can be fed to the infant14). CDC has recommended theexpressed milk feeding or breastfeeding with adequate precautions to prevent droplet
and contact transmissions11). Chinese expert consensus statement has recommended
that breast or expressed breast milk feedings could be started after the PCR test in abreast milk sample was proved negative15). However, there is currently very little
information on viral transmission through breastfeeding. Therefore, accurate
information should be provided based on future knowledge.
At this time, it is difficult to determine when the mother can start breastfeeding.
However, at least it is acceptable when the mother's symptoms are disappeared and therisk of infection to the infant seems to be reduced.
Questions and Answers (as of March 23, 2020)
Q1 How long should the infants born from the symptomatic mother infected with thecoronavirus be isolated?
A1 An average incubation period of the coronavirus has been reported between 3 and 7
days with the shortest of 1 day and the longest of 14 days15). Giving this information,
the isolation of 14 days should be applied currently. However, this could be changed if
symptoms of infected newborn infants clarified and the accuracy of tests became morereliable through studies of enough cases of newborn infants born from the positive
mothers16).
Q2 What are the necessary precautions for caregivers involving neonatal care to theinfants born from the positive mother and isolated inside an incubator?
A2 They need only a surgical face mask, gown, gloves if the infants isolated inside an
incubator. In case of procedures such as tracheal intubation and mechanical ventilation,a full set of protective gears should be used to prevent aerosol transmission.

Q3 How long should the positive mother be considered as infectious after her symptoms
disappeared before delivery?
A3 Chinese expert consensus statement has defined it should be at least 14 days15).
Q4 It is reasonable that the positive mother cannot enter the NICU until the risk oftransmission reduced. However, can the father visit the NICU? How to inform theinfant’s condition and to get informed consent? Should the infant be kept in NICU
during the quarantine of parents at home?
A4 All family members including the father living with the mother should be considered
as a close contact person. Therefore, all of them should not be allowed to visit the NICU
after the last exposure to the contracted person. Caregivers may inform the parents
about the infant’s condition and get informed consent from them through telephone
calls. Alternatively, it could be performed with other family members on behalf ofparents such as ground parents who are not living together and being exposed to any
patients recently. It is mandatory to keep the infant in NICU until all risks of infection
cleared. If not available, the only option is that other family members such as groundparents who are not living together and being exposed to any patients recently careabout the infant at their home.
Q5 Should the protective measures to the infant be changed based on delivery modes?
A5 Regardless of delivery modes (vaginal or Cesarean delivery), all infants born fromthe positive mother should be considered as close contact to the coronavirus.
Q6 Should all caregivers to touch the infant born from the positive mothers withsymptoms avoid contacting with other infants? Should they avoid contacting with other
healthcare providers?
A6 If the precaution with appropriate protective gear is secured, they do not need to
avoid contacting with others. Once incomplete procedures recognized, it should be
mandatory to take all necessary measures under the direction from the infectious
control team in a hospital.
References
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and intrauterine vertical transmission potential of COVID-19 infection in ninepregnant women: a retrospective review of medical records. Lancet.
2020;395:809-15.

2. Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, et al. Clinical analysisof 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr.
2020;9:51-60.
3. Schwartz DA. An Analysis of 38 Pregnant Women with COVID-19, Their Newborn
Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus
Infections and Pregnancy Outcomes. Arch Pathol Lab Med. 2020.
4. Lu Q, Shi Y. Coronavirus disease (COVID-19) and neonate: What
neonatologist need to know. J Med Virol. 2020.
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SARS-CoV-2 infection during pregnancy. J Infect. 2020.
6. Poon LC, Yang H, Lee JCS, Copel JA, Leung TY, Zhang Y, et al. ISUOG Interim
Guidance on 2019 novel coronavirus infection during pregnancy and puerperium:
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(Wuhan) Coronavirus 2019-nCoV Infecting Pregnant Women: Lessons from SARS,MERS,
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Investigation for COVID-19 in Healthcare Settings. [Cited 2020 March 22]. Avilable
at: https://wwwcdcgov/coronavirus/2019-nCoV/hcp/infection-controlhtml. 2020.
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[Cited 2020 March 22]. Avilable at:https://wwwcdcgov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-gui
dancehtml. 2020.
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Lancet Child Adolesc Health. 2020;4:e8.
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Note: This document is published in Japanese and is translated in English personallyfor your convenience, not officially approved.