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Characteristics and outcomes of neonatal SARS-CoV-2 infection in the UK: a prospective national cohort study using active surveillance

Our take —

This case series of neonates in the United Kingdom identified between March 1 and April 30, 2020, suggests that, at a population-level, SARS-CoV-2 infections are rare among neonates (~5.6 per 100,000 live births), even when COVID-19 cases are rising rapidly in a population. Clinical complications in neonates were higher than in older infants and children; however, neonates were only tested for SARS-CoV-2 infection in cases of suspected maternal infection, which may have overestimated the amount of severe disease in this study population.

Study design

Case Series

Study population and setting

This case series described characteristics and outcomes of neonates (aged 0-28 days) with confirmed SARS-CoV-2 infection who received inpatient care between March 1 and April 29, 2020 in the United Kingdom (UK). Neonates with a positive SARS-CoV-2 test were identified through the ongoing British Paediatric Surveillance Unit (BPSU), a surveillance program to study rare neonatal and pediatric diseases, as well as through data from Public Health England, Health Protection Scotland, the Paediatric Intensive Care Audit Network, and the UK Obstetric Surveillance System. All BPSU case reports were accompanied by a data collection form and BPSU staff manually collected data on non-BPSU reported cases. Severe disease met two of the following criteria: 1) one of temperature > 37.5C, apnea, cough, rapid breathing, respiratory distress, supplemental oxygen, poor feeding, diarrhea, or vomiting; 2) any of low white cell count, low lymphocyte count, or high c-reactive protein; and 3) abnormal chest x-ray. They presented descriptive statistics for characteristics of interest and calculated the incidence of neonates who received hospital care with COVID-19 using complete national birth data from the United Kingdom from 2018 (the most recent available full year data).

Summary of Main Findings

Among 118,347 live births in the UK between March 1 and April 30, 2020, including more than 300 mothers with confirmed SARS-CoV-2 infection, a total of 89 neonates with SARS-CoV-2 infection were identified in UK hospitals, resulting in , an incidence of 5.6 (95% CI 4.3-7.1) per 100,000 live birth. Twenty-eight of the neonates were diagnosed with severe disease (incidence 2.4 (95% CI 1.6-3.4) per 100,000 live births). SARS-CoV-2 incidence was higher among Black, Asian, or other minority ethnic group neonates (11.1/100,000; 95% CI 7.4-15.9), than white neonates (4.6/100,000; 95% CI 3.2-6.4). A majority (n=34; 52%) had a close contact with COVID-19 symptoms and seventeen (26%) were born to a mother who tested positive for SARS-CoV-2 within seven days of birth (before or after). There were two cases of suspected vertical transmission and 8 cases of suspected healthcare-acquired infection. The most common symptoms included temperature > 37.5C, poor feeding, or vomiting; seven (11%) neonates were asymptomatic and only tested because of their mother’s symptoms. Most (42, 64%) received care in the postnatal ward or pediatric unit, 20 (30%) received care in a neonatal unit, and four (6%) received care in the neonatal intensive care unit. Although 33% (n=22) required respiratory support, three requiring mechanical ventilation, none died from SARS-CoV-2, although one died from another cause.

Study Strengths

This study leveraged population-level surveillance data and additional data sources to maximize the identification of neonatal cases of SARS-CoV-2 infection in the United Kingdom.


This study used total population live births in their denominator and therefore did not calculate the incidence of neonatal SARS-CoV-2 infection among mothers with COVID-19. Furthermore, the surveillance system relied on health infrastructure that was strained by a global pandemic, which may have led to an underascertainment of cases and an underestimate of the neonatal SARS-CoV-2 population estimate. This may have been exacerbated by not testing for asymptomatic neonates except in cases of suspected maternal infection, which would also likely overestimate the complication rate of SARS-CoV-2 in neonates, as the results may only capture those with severe disease. Finally, the lack of a comparison group, control for potential confounding variables, longitudinal follow-up and this study’s small sample size precludes inferences about causality or risk factors and means it’s possible these findings may not generalize to all neonates with milder or less severe SARS-CoV-2 infection.

Value added

This study provided a population-level estimate and characterization of SARS-CoV-2 infections among neonates in the United Kingdom.

This review was posted on: 19 December 2020