Severe neonatal COVID‐19 pneumonia requiring mechanical ventilation

Abstract

The currently available epidemiologic reports regarding children with COVID-19 have suggested that critical cases are concentrated in adolescents rather than in younger children, although respiratory supports were rarely needed. Above all, neonatal cases requiring mechanical ventilation are quite limited. A 21-day-old term neonate, with an uneventful perinatal history, was admitted to a local hospital ward for isolation due to positive polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). He was asymptomatic on admission although both parents had already been diagnosed with symptomatic COVID-19 a few days before. Six hours after admission, he rapidly developed hypoxemia with oxygen saturation of 89% in ambient air and mild tachypnea (50 breaths/min). Venous blood gas analysis revealed respiratory acidosis with partial pressure of carbon dioxide of 55 mmHg. Concerns about his rapid oxygenation deterioration and young age led to urgent intubation and transportation to the pediatric intensive care unit (PICU). The patient was isolated in a negative-pressure room in the PICU, and mechanical ventilation was initiated on deep sedation and muscle paralysis along with empiric administration of cefotaxime. Due to poor respiratory system compliance, the patient required high driving pressure of 16 cm of water above a positive end-expiratory pressure of 8 cm of water to achieve a tidal volume of 6–7 mL/kg of bodyweight. Nevertheless, oxygenation was disproportionately maintained at PaO2/FiO2 ratio of approximately 300–400 mmHg. Chest radiograph and computed tomography revealed extensive bilateral infiltration in the dorsal lung areas, compatible with acute respiratory distress syndrome (Fig. 1), and the patient was diagnosed with severe COVID-19 pneumonia. On PICU admission, complete blood count (hemoglobin 11.4 g/dL, white cell count 4.7 9 10 /μL, and platelet 3.5 9 10/μL) and inflammatory markers (C reactive protein <0.03 mg/dL) were normal. Liver and kidney function tests were also within normal ranges. Blood culture on admission was negative, and respiratory viral panel (FilmArray Respiratory Panel 2.1, BioMeri eux, France) was also negative, except for SARS-CoV-2.