PONE-D-23-20437Associations of SARS-CoV-2 Antibodies with Birth Outcomes: Results from Three Urban Birth Cohorts in the NIH Environmental Influences on Child Health Outcomes ProgramPLOS ONE

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: The manuscript presents an attempt to evaluate the relationships of SARS-CoV-2 serology, self-reported infection, and pandemic-related stress with birth outcomes in largely urban cohorts from three ECHO cohort centers.

The pregnancy outcomes are well-defined and include gestational age (GA), birth weight (BW), and BW Z-score for gestational age (as continuous variables. Categorical outcomes included prematurity,

low birth weight (LBW) and small for gestational age (SGA).

The analyses did not document any differences in gestational age, birth weight, PTB, or LBW. Nearly identical results were obtained when comparing birth outcomes by serology status. The only positive association was the finding that children with lower birth weight and BW Z-score for GA (were more likely to deliver preterm in univariate models.

The study is performed in an elegant way and I do not have any major questions regarding the methodology.

The only point worth explaining is the way the final sample was identified. It is said that the study was nested within a subsample of mothers and newborns enrolled in three participating ECHO cohorts. Why three different cohorts were utilized? What were the criteria for inclusion and exclusion?

Reviewer #2: Here the authors aim at understanding the effect that SARS-CoV-2 infection has during or before pregnancy. In an observational study including three urban cohorts that gave birth between January 2020 to September 2021 they analyzed samples from 211 mothers for the presence of IgG1, IgG2, IgG3, IgG4, IgM and IgA subclass antibodies against N, S1, S2 and RBD areas of the spike protein. Pre-pandemic samples (n=234) were used to define non-infected antibody levels, and levels between 3-6 SD above background were classed as indeterminate whereas over 6 SD were considered positive. All mother with at least one subclass over 6SD were considered positive, mothers with a least on subclass in the 3-6 SD as indeterminate, and all classes below 3SD as negative. Seropositivity was seen in 36% of mothers, while 43% reported that they had been infected. IgG1 total seropositivity as well as reactivity against N and RBD was modestly correlated with reported infection. Neither serology + self reported infection nor serology alone was correlated with gestational age, birth weight, pre-term birth or low birth weight. IgM positivity was scored in 9 mothers, and in this case a significant decrease in birth weight was observed. This could not be solely explained by a posttraumatic stress score calculated from the mothers. In addition, in children born from mothers before any vaccines was available, decreased birth weights was also seen children born to IgM positive mothers.

During COVID-19 infection it has been shown that IgM antibodies occur in serum at approximately the same time as IgG and IgA antibodies. Since IgM then decrease more rapidly the data indicate that recent (possibly during pregnancy) infections with COVID-19 can influence pregnancy outcomes, but the authors argue caution as this result is only based on very few cases (n=9).

Overall, the study is of interest although its main conclusion is based on very few samples. It is well written, the data is presented in a clear and careful way, and the results are discussed cautiously. Although the data will not overall change the general recommendation to try to avoid infection with SARS-CoV- 2 during pregnancy, it gives some further support to the recommendation.

Specific points

I think the material is big enough to not only discuss the potential correlation between IgM antibodies and pregnancy/birth related problems but also the lack of any correlation to IgG levels. This could suggest that it is unlikely that pre-pregnancy (or even early pregnancy) infections will not interfere with outcomes. I fully understand that it is hard to rule out that this could be due to early problems are not scored (i.e. problems conceiving or early spontaneous abortion), but at least late problems from previous infection are unlikely. I would suggest a short paragraph about this in the discussion.

On line 234, the sentence “When we compared mothers by immunoglobulin subtype (Table 2c), the small number of IgM seropositive mothers in the sample (n=9) had children with 407 grams lower birth weight (95% CI: 85-728) and BW Z-score for GA (0.65 SD; 95% CI 0.002-1.30) were more likely to deliver preterm (OR 6.29, 95% CI 1.12-25.2) in univariate models.” Is very hard to understand – please reformulate.

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Reviewer #1: Yes: Wojciech Hanke

Reviewer #2: No

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Associations of SARS-CoV-2 Antibodies with Birth Outcomes: Results from Three Urban Birth Cohorts in the NIH Environmental Influences on Child Health Outcomes Program

PONE-D-23-20437R1

Dear Dr. Trasande

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Faten Abdelaal Okda

Academic Editor

PLOS ONE

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