Challenges for the Pediatricians During the Coronavirus Disease 2019 Pandemic Start From the Neonatal Period.

To the Editors,

We read with interest the recent article published by Chidini et al[1] referring to the challenges encountered in the management of severe acute respiratory syndrome coronavirus 2 infection in children in Milan. This is actually the current situation in various pediatric departments throughout Europe. We fully agree with the suggested management and approach, although the latter still poses major further logistical issues such as the availability of negative pressure rooms for all inpatients with suspected COVID-19 infection pending virologic confirmation. Moreover, 2 negative respiratory samples are required to rule out severe acute respiratory syndrome coronavirus 2 infection which means further inpatient stay and more resources needed. More data in the field are urgently required to guide the pediatricians further.

Apart though from the management of febrile children, pediatricians and the pediatric infectious diseases specialists will also have to face challenges with the infection during the neonatal period. Undoubtedly close monitoring of at-risk neonates is essential in the neonatal wards, but there are issues where evidence-based guidance is needed. The first priority is identifying the timing of infection (antenatally, perinatally or postnatally) and confirming its presence. Two recent reports from China suggest that in utero infection could be possible based on the measurement of IgM levels in neonates shortly after birth but no further confirmation of this with a positive reverse transcriptase–polymerase chain reaction test.[2,3] Therefore, although in utero transmission is possible, larger studies on infected women will bring further insight in the field. In the case of the in utero infected neonate, the timing of infection may have an impact on fetal development and possibly on long-term outcomes. We do not know as yet whether acquisition during first trimester of pregnancy is associated with birth defects and whether fetal infection is more likely in the advanced pregnancy stages following the patterns of other congenital infections. What we do know though is that antenatal infection with other coronaviruses (severe acute respiratory syndrome and Middle East respiratory syndrome) is associated with possible miscarriage, intrauterine growth retardation prematurity and low birth weight.[4] Moreover, at present, we do not know how many molecular tests we need to perform and whether 2 tests are enough to rule out neonatal infection given that serology is not always reliable, as observed with other congenital infections. In addition to that, uncertainty exists as to whether respiratory specimens are enough or blood, stool or urine samples would offer more accurate results.

Last but not least separation of an infected mother from her offspring and feeding options are issues for further consideration. Some guidelines suggest complete separation of a COVID-19-positive mother and her baby for at least 14 days or until viral shedding clears, during which time direct breast-feeding is not recommended.[5] On the other hand, the Centre for Disease Control and Prevention and the Royal College of Obstetricians and Gynecologists recommend breast-feeding with strict contact precautions based on the fact that so far there is no evidence that the virus can be transferred via breast milk. For those women who are too sick to breast-feed, the recommendation is breast milk expression and avoidance of any contact with the baby.

In conclusion, the current pandemic poses several challenges to the pediatricians from the neonatal period throughout adolescence. Evidence-based recommendations are lacking at present, and future research in pediatric COVID-19 should also focus on neonates.