Increasing numbers of pregnant women with COVID-19 are being reported around from the world. The majority of neonates delivered to pregnant women infected with the new coronavirus SARS-CoV-2 have been negative for the virus, but a small number have tested positive for infection. It is important to determine whether vertical transmission of COVID-19 occurs and the mechanisms for its development. Based on a number of clinical and laboratory findings it has been suggested that transplacental transmission may be occurring, but a method to confirm this is necessary. This communication analyzes and evaluates the covariables that have been discussed as potential indicators of vertical and, specifically, intrauterine transmission including the timing of onset of neonatal illness, neonatal viral test positivity, neonatal antibody testing for IgG and IgM, and viral analysis of swabs of whole specimens of placental tissue. None of these methods can provide confirmatory evidence that infection developed prior to labor and delivery, or that transplacental transmission occurred. This commentary proposes that diagnosis of early-onset neonatal COVID-19 infection should be limited to neonates with positive RT-PCR testing for SARS-CoV-2 within the initial 72 hours of life. It also proposes that the occurrence of intrauterine transplacental SARS-CoV-2 among infected mother-infant dyads be based upon identification of SARS-CoV-2 in chorionic villous cells using immunohistochemistry or such nucleic acid methods such as in situ hybridization. Evaluating placentas from neonates with COVID-19 using these methods will be instrumental in determining the potential role and prevalence of transplacental transmission of the coronavirus.

Background: There have been few cohorts of neonates with coronavirus disease-2019 reported. As a result, there remains much to be learned about mechanisms of neonatal infection including potential vertical transmission, best methods of testing, and the spectrum of clinical findings. This communication describes the epidemiology, diagnostic test results and clinical findings of neonatal COVID-19 during the pandemic in Iran. Materials and methods: This is a retrospective cohort study of 19 neonates infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from 10 hospitals throughout Iran. We analyzed obstetrical information, familial COVID-19 status, neonatal medical findings, perinatal complications, hospital readmissions, patterns of repeated testing, and clinical outcomes. Results: Eleven neonates had family members infected. Five mothers were negative for COVID-19 and four neonates had no identifiable family source of infection. The neonatal mortality rate from COVID-19 was 10%. Seven newborns (37%) were discharged from the hospital as healthy but required readmission for symptoms of COVID-19. There were 2 multifetal gestationsone set each of twins and triplets, each with disparate testing and clinical outcomes. Premature delivery was common, occurring in 12 of 19 infants (63%). Initial testing for COVID-19 was negative in 4 of the 19 neonates (21%) who subsequently became positive. In 2 cases, neonates tested positive at 1 and 2 h after birth which was suspicious for vertical transmission of SARS-CoV-2. Conclusions: These cases have notable variation in the epidemiology, clinical features, results of testing and clinical outcomes among the infected newborns. Neonates initially testing negative for COVID-19 may require readmission due to infection. Two neonates were highly suspicious for intrauterine vertical transmission. Repeat testing of neonates who initially test negative for COVID-19 is recommended, without which 21% of neonatal infections would have been undiagnosed.

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