This is the story of a premature baby girl who developed SARS-CoV-2 coronavirus infection.
This clinical case is reported in an article published on May 7 in the journal The Lancet Child & Adolescent Health. It all starts when a pregnant woman is transferred from a peripheral hospital to the Cliniques Universitaires Saint-Luc (Brussels, Belgium) because she suffers from pre-eclampsia (arterial hypertension of recent onset and presence of protein in the urine) and also presents suspected gallbladder inflammation (cholecystitis). She is treated with intravenous antibiotics. The patient showing signs of worsening of pre-eclampsia *, delivery is scheduled by Cesarean section 48 hours later. Birth takes place at 26 weeks of pregnancy.
The little girl is therefore very premature, extreme prematurity corresponding to a birth before 28 weeks of gestation (before six months of pregnancy). The child weighs only 960 grams. The little girl was immediately admitted to neonatal intensive care because her great prematurity exposed her to respiratory complications. She receives oxygen in the mask and surfactant, a substance which helps the alveoli to remain open and which is not produced by the body in sufficient quantity until a relatively late stage of gestation (34 to 36 weeks). The child develops a pneumothorax which requires the installation of a drain to evacuate the air between the two layers of the pleura, the membrane which covers the lungs and lines the inside of the chest wall.
The baby is kept in a closed incubator. The day after cesarean, the mother has a fever while receiving antibiotic treatment. The level of C-reactive protein (CRP), a marker of inflammation, which was 39 mg / L (normal values less than 5 mg / L) upon admission, increased to 85 mg / L. Twenty-four hours later, it reaches 214 mg /The mother always wears a surgical mask when she goes to the neonatal intensive care unit to see her baby because she has a fever and she coughs.
She returns home five days after her admission. Skin-to-skin contact The next day, the mother has her first and only skin-to-skin contact with her baby. That day, she is referred to the emergency room because she has a fever and has difficulty breathing. A chest x-ray is taken which reveals bilateral pneumonia. The nasopharyngeal sample returns positive for the SARS-CoV-2 coronavirus.
It has been seven days since this woman gave birth. The patient has had no known contact with Covid-19 or recent travellers. The mother is then confined to her home and is not authorized to return to the hospital, or to the neonatology service until she has no more symptoms and the PCR test becomes negative. A 7-day-old baby infected with SARS-CoV-2 As soon as the mother is diagnosed with Covid-19, a nasopharyngeal sample is taken from her baby. He returned positive for SARS-CoV-2 a few hours later.
The little girl is then placed in solitary confinement. As for the nursing staff, they adopt adequate protective measures, in particular, to avoid the spread of the virus by aerosols and droplets. A PCR test on breast milk is carried out: no trace of the genetic material of SARS-CoV-2 is detected. Ten days late (D17 after admission), the baby’s chest X-ray shows anomalies in the two pulmonary fields (reticular infiltrates), but his clinical state is stable. The little girl continues to receive oxygen through non-invasive ventilation.
She has no fever. Carried out seven days after the first PCR test, a second test returns positive. A third, made after 14 days, comes back negative. In the mother, the negativation of the PCR test is observed only after 21 days. “Horizontal” transmission So far, no study published in the medical literature has documented direct, in utero, (“vertical transmission”) passage of SARS-CoV-2 from mother to child.
The case reported by neonatologists, obstetricians and pediatric infectious disease specialists in Brussels undoubtedly corresponds to a “horizontal transmission”, that is to say, the fact that an infected person transmits the disease to another uninfected. In this case, the mother contaminated her baby after birth. The route of contamination was not linked to breast-feeding since the coronavirus was not detected in breast milk, it is understood that the mother adopted the barrier measures. “The mother always wore a mask in the neonatal intensive care unit because she had an unidentified febrile infection. It is therefore likely that she contaminated her baby, kept in an incubator, by touching him.
However, it was not until seven days after the birth of the child that the mother’s infection was found to be due to the SARS-CoV-2 coronavirus, ”explains Fiammetta Piersigilli, neonatologist. Once the diagnosis of Covid-19 was made in the mother and baby, the caregivers, other children and parents who had been near or in contact with the contaminated baby girl were tested for SARS- CoV-2 or followed for fourteen days. This mother-child contamination occurred at the start of the Covid-19 epidemic in Belgium, at a time when there were only around 250 cases and when only two Covid-19 patients were hospitalized at Cliniques Universitaires Saint-Luc. It is therefore unlikely that the baby’s infection has a nosocomial origin via aerosol contamination or by an infected individual belonging to the nursing staff. Reinforced precautionary measures “After the occurrence of this case, the mother has given birth on March 1, new procedures were quickly implemented.
Visits by grandparents, brothers and sisters are now prohibited in the neonatal care unit. We no longer allow the simultaneous presence of both parents, but only one parent in bed for the newborn. We allow the skin to skin contact. Before entering the unit, parents and caregivers should indicate if they have recently had a fever or respiratory symptoms. Today, we also check their temperature at the entrance.
The surgical mask is also compulsory for parents and staff, ”says Fiammetta Piersigilli, who adds that breastfeeding is not contraindicated. This clinical case shows that newborns infected with SARS-CoV-2, even in the case of very premature babies, would not necessarily develop severe disease. Several hypotheses could explain it. In particular, it remains to be seen whether, at this age, the immune response against the SARS-CoV-2 coronavirus is not accompanied by a major inflammatory reaction (which can be very deleterious) or whether the respiratory tract cells of the young children express only small amounts of the ACE2 receptor which acts as a cellular gateway to the virus. Since then, five more children have been born to Covid-19 mothers on the ward.
All were tested negative for SARS-CoV-2. Belgian doctors have undertaken, in association with a network of Italian neonatologists, to create a database grouping together all of the neonatal Covid-19 cases in order to better define their incidence, clinical presentation and prognosis. But back to the premature baby infected with SARS-CoV-2, the case of which was reported by Brussels doctors. The little girl remained in intensive care waiting to have an age corresponding to the date of the term. Good news: “she left the hospital yesterday, Wednesday, May 13,” says Fiammetta Piersigilli.
* In this context of preeclampsia, the mother developed a “HELLP syndrome”(Hemolysis, Elevated Liver enzymes and Low Platelets) associating hemolysis (destruction of red blood cells), elevation of liver enzymes and thrombocytopenia (drop in blood platelet levels). To find out more: Piersigilli F, Carkeek K, Hocq C, van Grambezen B, Hubinont C, Chatzis O, Van der Linden D, Danhaive O. COVID-19 in a 26-week preterm neonate. Lancet Child Adolesc Health. 2020 May 7.
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