Since December 2019, a novel coronavirus since named SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19) has given rise to a global pandemic.

In June 16, 2020, the World Health Organization reported that there had been 8 035 583 cases and 436 918 deaths worldwide.1 In children, most cases manifest with mild upper respiratory symptoms or are asymptomatic.2 At the moment, the evidence on the presentation and outcomes of cases in neonates is scarce.3

We present the cases of 3 neonates infected by SARS-CoV-2 managed in the department of paediatrics of our hospital. Table 1 summarises the clinical and laboratory characteristics of the cases.

Patient 1 was a neonate aged 4 days brought to the emergency department due to weight loss associated with maternal hypogalactia. The infant had no fever or rhinorrhoea. Per hospital protocol, the mother had undergone a polymerase chain reaction (PCR) test for detection of SARS-CoV-2 before delivery, which turned out negative. The examination in the emergency department revealed a weight loss of 15% of the birth weight and moderate dehydration that prompted initiation of intravenous fluid therapy. There were no abnormal findings in the physical examination. The vital signs were as follows: heart rate, 148 beats per minute; respiratory rate, 40 breaths per minute; oxygen saturation (pulse oximetry) 98%; axillary temperature, 36.6 °C. Since the patient had to remain in the observation unit of the department, a nasopharyngeal aspirate sample was obtained to perform a SARS-CoV-2 PCR test, which was positive; there were no other abnormal findings of laboratory tests. The patient improved while under observation and was discharged from the emergency department after 12 h. The patient was followed up for one month post discharge through telephone calls, which confirmed the absence of symptoms and adequate weight gain.

Patient 2 was a neonate aged 25 days referred due to fever (maximum axillary temperature, 38 °C) of 16 h’ duration with no other symptoms. Positive history of exposure in the home environment to a parent with cold symptoms and fever. The physical examination was normal. The vital signs in the emergency department were: heart rate, 136 beats per minute; respiratory rate, 38 breaths per minute; oxygen saturation, 99%; rectal temperature, 37.1 °C. Tests for viral detection were performed in nasopharyngeal aspirate samples, and were negative for influenza and respiratory syncytial virus, and positive for SARS-CoV-2. The results of blood tests were normal. The patient was discharged home after 8 h under observation due to his excellent general health and afebrile status. Telephone calls made to follow-up in subsequent weeks ascertained that the patient had a favourable outcome.

Patient 3 as a neonate aged 28 days brought in with fever (maximum temperature of 38.6 °C) lasting 24 h. The patient had no cough, rhinorrhoea or any other associated symptoms. There was no evidence of exposure to infectious disease in the environment. The physical examination in the emergency department was normal, with a heart rate of 136 beats per minute, a respiratory rate of 30 breaths per minute, an oxygen saturation of 99% and a rectal temperature of 37.2 °C. The results of blood tests were normal. Viral detection tests in nasopharyngeal aspirate samples were negative for influenza and respiratory syncytial virus, but positive for SARS-CoV-2. The patient remained in the observation unit for 12 h, during which he remained afebrile and in excellent general health, so he was discharged home. The follow-up telephone calls made in the month following discharge evinced that everything remained normal.

Few data have been published on the clinical presentation of SARS-CoV-2 infection in neonates or young infants. None of the patients in our series exhibited respiratory symptoms during the course of disease: one was asymptomatic at all times and the other 2 had fever as the sole symptom. Due to the absence of respiratory symptoms, imaging tests were not deemed necessary, as established in the protocol for management of viral infections to avoid unnecessary exposure to radiation. In China, in the early days of the pandemic, computed tomography scans and chest radiographs were frequently done in infected children but did not yield useful information in asymptomatic patients.4 Adding to the clinical experience acquired throughout the pandemic, these cases support adhering to the general approach of avoiding unnecessary irradiation in infants without clinical features suggestive of lower respiratory tract involvement in cases of paediatric infection by SARS-CoV-2.

The most recent guidelines of the Asociación Española de Pediatría (Spanish Association of Pediatrics) call for restricting plain chest radiography to patients with respiratory manifestations requiring hospital admission.5 Our findings corroborate that in the absence of signs or symptoms suggestive of pneumonia, the clinical condition of infants is good and fever is self-limiting, so it is better to avoid the exposure to radiation involved in a test that is unlikely to yield any benefits.6