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The Direct and Indirect Impact of SARS-CoV-2 Infections on Neonates: A Series of 26 Cases in Bangladesh

Our take —

This study reported a high positivity rate of SARS-CoV-2 testing among neonates (aged 0-28 days) in serious condition at a referral center in Bangladesh. Six of the 8 babies who died had serious comorbidities that are commonly seen in neonates in low and middle-income countries (LMICs). Although half of the cases were identified within the first 5 days after birth, many neonates suffered from delays or gaps in treatment. In some cases, these delays were caused by the COVID-19 diagnosis itself, because the pediatric referral center was not equipped with adequate infection control procedures to perform necessary treatment. This study highlights the amplified risks of SARS-CoV-2 infection for distressed neonates in LMICs.

Study design

Case Series

Study population and setting

This study reports on 26 neonates (aged 0-28 days, median age 8 days, 62% male) with laboratory-confirmed SARS-CoV-2 infection who were admitted to the largest pediatric referral hospital in Bangladesh, from March 29 to July 1, 2020. Neonates with confirmed infections were transferred to designated COVID-19 care hospitals for further treatment. Demographic and clinical data were collected prospectively with standardized forms. Outcomes were assessed via standardized telephone questionnaires through July 28, 2020.

Summary of Main Findings

Of 83 neonates tested, 26 (31%) were positive for SARS-CoV-2 infection. All neonates were born at term. Half were referred to the hospital and identified as COVID-19 cases within the first five days after birth. Four babies died before leaving the hospital. Of the 22 babies who left the hospital alive, 19 were followed up for outcomes; follow-up time for those who did not die ranged from 8 to 102 days. Four babies died during follow-up, 3 required continuing medical care, and 12 recovered. Seven babies initially presented with symptoms of early onset neonatal sepsis (EONS), while 5 had clinical signs of late onset neonatal sepsis (LONS). Two babies presented with pneumonia; one died, while the other was lost to follow-up. Eleven neonates had serious non-communicable diseases at admission, including ruptured myelomeningocele, anocutaneous fistula, ruptured occipital encephalocele, anorectal malformation, obstructive uropathy, and congenital heart disease. Of the 8 babies who died, 6 had serious comorbidities. Among the 9 immediate caregivers (8 mothers and one grandmother) who were tested for SARS-CoV-2 infection at time of neonate specimen collection, 8 tested positive. Among the 11 other mothers who were not tested but who were interviewed, 2 reported symptoms consistent with COVID-19 in the days before delivery.

Study Strengths

This study reported on a substantial number of cases relative to previous reports of SARS-CoV-2 infection in neonates. A large number of clinical and laboratory parameters were measured and reported.


Neonates were transferred to another facility because of their COVID-19 status and three were lost to follow-up. Cases were limited to those in serious condition, since they were drawn from a referral center; thus, the cases were at high risk of death and no asymptomatic or mild cases were detected. Maternal SARS-CoV-2 infection status was only assessed for a subset (8/26) of neonates. X-rays (5/26) and other laboratory tests were only performed on a limited number of patients. Follow-up duration was not sufficient to assess incidence of longer-term sequelae such as multisystem inflammatory syndrome in children (MIS-C).

Value added

This is among the largest reported case series of neonatal SARS-CoV-2 infection, and the first from the South Asian region and a low and middle-income country.

This review was posted on: 10 November 2020