Management of COVID-19 in children

Management of COVID-19 in children

Asymptomatic

Suspected contact [RAT or RTPCR negative or not available]

Incidentally detected [RAT or RTPCR positive]

Take 6 min walk test in children above 12 years under supervision of parents/guardian; See 6-minute walk test – at a glance

Home isolation

(tele consultation SOS)

Mainstay of treatment

Infants and younger children to stay under immediate care of parents/guardians

No specific medication required for COVID-19 infection

Continue medications for other conditions, if any

Promote COVID appropriate behaviour (mask, strict hand hygiene, physical distancing); please see Children and masks guide

Fluids and feeds: ensure oral fluids to maintain hydration and give a nutritious diet

Advise older children and family to stay connected and engage in positive talks through phone, videocalls, etc.

Parent/caregivers to contact the doctor in case of deterioration of symptoms

Investigations

No investigations are needed

Mild

Sore throat or rhinorrhoea

Cough with no breathing difficulty

SPO2 ≥ 94% on room air

Take 6 min walk test in children above 12 years under supervision of parents/guardian; please see 6-minute walk test – at a glance

For other symptoms, see COVID-19 symptoms – at a glance

Home isolation

(tele consultation SOS)

Mainstay of treatment

Promote COVID appropriate behaviour (mask, strict hand hygiene, physical distancing); please see Children and masks guide

For fever, give paracetamol 10-15mg/kg/dose; may repeat every 4-6 hours

For cough: throat soothing agents and warm saline gargles in older children and adolescents

Fluids and feeds: ensure oral fluids to maintain hydration and give a nutritious diet

No other COVID-19 specific medication needed

Antimicrobials are not indicated

Maintain monitoring chart including counting of respiratory rate 2-3 times a day, look for chest indrawing, bluish discoloration of body, cold extremities, urine output, oxygen saturation, fluid intake, activity level, especially for young children

Advise older children and family to stay connected and engage in positive talks through phone, videocalls, etc.

Parent/caregivers to contact the doctor in case of deterioration of symptoms

Investigations

No investigations are needed

Moderate

In addition to symptoms in mild cases, check for pneumonia which may not be apparent

Rapid respiration (age-based): <2 months RR >60/min; 2-12 months, RR >50/min; 1-5 years, RR >40/min; >5 years, RR >30/min

SpO2 : 90-93 % on room air

For other symptoms, see COVID-19 symptoms – at a glance

Admit in DCHC or COVID-19 Hospital

Mainstay of treatment

Initiate immediate oxygen therapy

Maintain fluid and electrolyte balance

Encourage oral fluids (breast feeds in infants)

Initiate intravenous fluid therapy if oral intake is poor

Corticosteroids are not required in all children with moderate illness; they may be administered in rapidly progressive disease

Anticoagulants may also be indicated

Exercise caution and see use of corticosteroids and anti-coagulants guide

For fever (temperature >38°C or 100.4°F): Paracetamol
10-15mg/kg/dose; may repeat every 4-6 hours

Anti-microbials to be administered if there is evidence/strong suspicion of superadded bacterial infection. See anti-microbial use guide

Supportive care for comorbid conditions, if any

Activate the Hospital Infection Control Committee

Investigations

Baseline lab investigations: CBC, Blood Glucose, urine routine, LFT, KFT, CRP, S. Ferritin, D-Dimer, LDH, CPK.

Repeat investigations: CRP and D-Dimer 48 to 72 hourly; CBC, KFT, LFT 24 to 48 hourly; IL-6 (subject to availability)

Investigations may have to be repeated more frequently in ICU settings; serial CXR should be at least 48 hours apart

HRCT chest to be done ONLY if there is worsening of symptoms, please see rational use of HRCT imaging guide

Severe

SpO2 < 90% on room air

Signs of severe pneumonia, acute respiratory distress syndrome, septic shock, multi-organ dysfunction syndrome, or pneumonia with cyanosis, grunting, severe retraction of chest, lethargy, somnolence, seizure; assess for thrombosis, hemophagocytic lymphohistiocytosis (HLH)

Please see COVID-19 symptoms – at a glance

Admit in HDU/ICU of
COVID-19 Hospital

Mainstay of Treatment

Initiate immediate oxygen therapy

Maintain fluid and electrolyte balance

Corticosteroids therapy to be initiated

Anticoagulants may also be indicated

Exercise caution and see use of corticosteroids and anti-coagulants guide

In case Acute Respiratory Distress Syndrome (ARDS) develops, necessary management to be initiated; see ARDS and Shock guide

In case shock develops, necessary management to be initiated; see ARDS and Shock guide

Anti-microbials to be administered if there is evidence/strong suspicion of superadded bacterial infection. See anti-microbial use guide

May need organ support in case of organ dysfunction, e.g. renal replacement therapy

Activate the Hospital Infection Control Committee

Investigations

Baseline lab investigations: CBC, Blood Glucose, urine routine, LFT, KFT, CRP, S. Ferritin, D-Dimer, LDH, CPK.

Repeat investigations: CRP and D-Dimer 48 to 72 hourly; CBC, KFT, LFT 24 to 48 hourly; IL-6 (subject to availability)

Investigations may have to be repeated more frequently in ICU settings; serial CXR should be at least 48 hours apart

HRCT chest to be done ONLY if there is worsening of symptoms, please see rational use of HRCT imaging guide

6-MINUTE WALK TEST – at a glance

To be used in children above 12 years under supervision of parents/guardian

It is a simple clinical test to assess cardio-pulmonary exercise tolerance, and is used to unmask hypoxia

Attach pulse oximeter to his/her finger and ask the child to walk in the confines of their room for 6 minutes continuously

Positive test: any drop in saturation < 94%, or absolute drop of more than 3–5% or feeling unwell (lightheaded, short of breath) while performing the test or at end of 6 minutes

Children with positive 6-minute walk test may progress to become hypoxic and early admission to hospital is recommended (for observation and oxygen supplementation)

The test can be repeated every 6 to 8 hours of monitoring in home setting; avoid the test in patients with uncontrolled asthma

Acute Respiratory Distress Syndrome (ARDS) and shock management guide

Management/treatment of ARDS

ARDS may be classified based on Pediatric Acute Lung Injury Consensus Conference (PALICC) definition into mild, moderate and severe

Mild ARDS: high flow nasal oxygen, non-invasive ventilation may be given

Moderate to severe ARDS: lung protective mechanical ventilation may be initiated

o Low tidal volume (4-8 ml/kg); peak pressure <28-30 cmH2O; MAP <18-20 cmH2O; driving pressure <15 cmH2O;PEEP 6-10 cmH2O (or higher if severe ARDS); FiO2 <60%; sedoanalgesia ± neuromuscular blockers; cuffed ETT, inline suction, heat and moisture exchange filters (HMEF), avoid frequent disconnection, nebulization/metered dose inhaler

o Restricted fluids, calculate fluid overload percentage (FO%) and keep it <10%

o Awake prone position may be considered in older hypoxemic children if they are able to tolerate it

o Daily assessment for weaning and early extubation; enteral nutrition within 24 hours, achieve full feeds by 48 hours

o Transfusion trigger Hb <7g/dL if stable oxygenation and haemodynamics and <10 g/dL if refractory hypoxemia or unstable shock

If the child does not improve, may consider high frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation(ECMO) if available Management of shock

Consider crystalloid fluid bolus 10-20 ml/kg over 30-60 minutes (fast in presence of hypotension) with early vasoactive support (epinephrine)

Consider inotropes (milrinone or dobutamine) if poor perfusion and myocardial dysfunction persists despite fluid boluses and vasoactive drugs and achievement of target mean arterial pressure(MAP)

Once stabilized proceed for restricted fluids and early de-resuscitation

Hydrocortisone may be added if there is fluid refractory catecholamine resistant shock (avoid if already on dexamethasone or methylprednisolone)

Initiate enteral nutrition; sooner the better

Transfusion trigger Hb <7g/dL if stable oxygenation and haemodynamics, and <10 g/dL if refractory hypoxemia or unstable shock

Multisystem Inflammatory Syndrome (MIS-C) management guide

Multi System Inflammatory Syndrome in Children (MIS-C) is a new syndrome in children characterized by unremitting fever >38°C and epidemiological linkage with SARS-CoV-2. It usually occurs after 2–4 weeks of recovery from acute COVID-19 Diagnostic criteria (WHO)

Children and adolescents 0–18 years of age with fever ≥3 days

And any two of the following:

o Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral, hands or feet)

o Hypotension or shock

o Features of myocardial dysfunction, pericarditis, valvulitis, or coronary abnormalities (including ECHO findings or elevated Troponin/NT-proBNP)

o Evidence of coagulopathy (PT, PTT, elevated D-Dimer)

o Acute gastrointestinal problems (diarrhoea, vomiting, or abdominal pain)

And elevated markers of inflammation such as ESR, C-reactive protein, or procalcitonin

And no other obvious microbial cause of inflammation, including bacterial sepsis, staphylococcal or streptococcal shock syndromes

And evidence of recent COVID-19 infection (RT-PCR, antigen test or serology positive), or likely contact with patients with COVID-19 Treatment– The child needs appropriate supportive care preferably in ICU for treatment of cardiac dysfunction, shock, coronary involvement, multi-organ dysfunction.

Drugs to be used are:

Intravenous immunoglobulin (IVIG): 2g/kg over 12 to 24 hours

Steroids: methylprednisolone 1-2mg/kg/day

Empirical broad spectrum antimicrobials If the child does not improve with the above treatment or deteriorates, options include:

Repeat IVIG

High dose corticosteroid (methylprednisolone 10-30 mg/kg/day for 3-5 days); have to be tapered over 2 to 3 weeks while monitoring inflammatory markers

Aspirin: 3mg/kg/day to 5 mg/kg/day, max 81mg/day (if thrombosis or coronary aneurysm score is >2.5)

Low molecular weight heparin (Enoxaparin): 1mg/kg twice daily subcutaneously (if patient has thrombosis or giant aneurysm with absolute coronary diameter ≥ 8 mm or ≥ 10 Z score (coronary aneurysm score ≥ 10) or LVEF < 30% or D-Dimer ≥ 5 ULN); clotting factor Xa should be between 0.5 to 1 IU/ml

Use of biologicals only after expert consultation and should be used at tertiary care only

For children with cardiac involvement, repeat ECG 48 hourly & repeat ECHO at 7–14days and between 4 to 6 weeks (and after 1 year if initial ECHO was abnormal)

ANTIMICROBIAL USE guide

COVID-19 is a viral infection, and antimicrobials have no role in prevention or treatment of uncomplicated COVID-19 infection

Asymptomatic and mild cases: antimicrobials are not recommended for therapy or prophylaxis

Moderate and severe cases: antimicrobials should not be prescribed unless there is clinical suspicion of a superadded infection; hospital admission increases risk of healthcare-associated infections with multidrug-resistant organisms

Septic shock: empirical antimicrobials (according to body weight) are frequently added to cover all likely pathogens based on clinical judgement, patient host factors and local epidemiology and antimicrobial policy of the hospital, and are usually needed when there is leucocytosis with neutrophilia, very high inflammatory markers, or raised procalcitonin (which may also be raised in severe trauma, burns, multiorgan failure, major surgery or chronic kidney disease)

Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces drug resistance, and decreases the spread of infections caused by multidrug-resistant organisms; it should be integrated into the pandemic response across the broader health system through the following:

1. Reduce/eliminate unnecessary antimicrobial use– through careful selection of antimicrobials as per national/hospital treatment guidelines for their empiric use in children

2. AWaRe (Access, Watch and Reserve) classification in the Essential List of Medicines is a tool for antibiotic stewardship – antimicrobials are divided into 3 categories based on their indication for common infections, their spectrum of activity and their potential for increasing antimicrobial resistance; use access group AMs for community acquired infections

3. Strengthen microbiology laboratories to reduce turnaround time of COVID-19 testing and other infections by improving test methods and expanding testing facilities

4. Diagnostic stewardship – collect blood cultures and other appropriate samples for culture before starting antimicrobials, which should preferably be administered within 1 hour of clinical assessment, with daily assessment for de-escalation and substituting IV route to oral once patient is stabilized

5. Infection prevention and control– implement/strictly enforce standard/transmission-based precautions, surveillance of HAI and other IPC measures

6. Monitor trends of antimicrobial resistance and antibiotic consumption/use, including Remdesivir, through audits/review and share/feedback of results and impact of interventions

7. Education and training to improve clinical competence among health workers treating COVID-19 patients – key competencies include ability to identify signs and symptoms of severe COVID-19 and those of a superimposed bacterial or fungal disease, and evaluating the need for medical devices that increase risk of healthcare associated infections (HAI)

8. Ensure continuity of essential health services and regular supply of quality assured and affordable antimicrobials, including antiretroviral/tuberculosis drugs and vaccines

9. Use biocides cautiously for environmental and personal disinfection – prioritize biocidal agents without, or with a low, selection pressure for antimicrobial resistance

10. Address gaps in research to ensure that antimicrobial stewardship activities become an integral part of the pandemic response and beyond; research agenda includes rapid and affordable diagnostic tests that differentiate between bacterial and viral respiratory tract infections; short- and long-term impact of wide use of biocides for environmental and personal disinfection including cross resistance to antimicrobials; and R&D for newer drugs, vaccines (COVID-19 and others) and potential alternatives to antimicrobials

These measures would reduce the emergence of untreatable multi-drug resistant infections and diseases that could potentially lead to another public health emergency

Guide for use of remdesivir

Remdesivir (an emergency use authorization drug) is NOT recommended in children

There is lack of sufficient safety and efficacy data with respect to Remdesivir in children below 18 years of age

Guide for using masks

Children aged 5 years and under should not be required to wear masks

Children aged 6-11 years may wear a mask depending on the ability of child to use a mask safely and appropriately under direct supervision of parents/guardians

Children aged 12 years and over should wear a mask under the same conditions as adults

Ensure hands are kept clean with soap and water, or an alcohol based hand rub, while handling masks

USE of STEROIDS and ANTI-COAGULANTS guide

Steroids

Steroids are not indicated and are harmful in asymptomatic and mild cases of COVID-19

Indicated only in hospitalized moderately severe and critically ill COVID-19 cases under strict supervision

Steroids should be used at the right time, in right dose and for the right duration

Self-medication of steroids must be avoided

Indications and recommended dose: Corticosteroids may be used in rapidly progressive moderate and severe cases. The recommended dose is as below: .

o Dexamethasone 0.15 mg/kg per dose(maximum 6 mg) twice a day or equivalent dose of methylprednisolone may be used if dexamethasone is unavailable, for 5–14 days depending on clinical assessment on daily basis

It must be remembered that steroids prolong viral shedding and hence caution is required in their use.

Anti-coagulants

Recommended dose in severe COVID-19 and MIS-C

o Aspirin: 3 mg/ kg/day to 5 mg/kg/day max 81 mg/ day (if thrombosis or Coronary aneurysm score ≥ 2.5)

o Low molecular weight heparin (Enoxaparin): 1mg/kg twice daily subcutaneously

o Clotting factor Xa should be between 0.5–1 IU/ml (if patient has thrombosis or coronary aneurysm score >10 or LVEF <30%)

RATIONAL USE of HRCT IMAGING guide

High-resolution CT (HRCT) scan of chest provides better visualization of the extent and nature of lung involvement in patients with COVID-19

However, any additional information gained from HRCT scan of chest often has little impact on treatment decisions, which are based almost entirely on clinical severity and physiological impairment

Therefore, treating physicians should be highly selective in ordering HRCT imaging of chest in COVID-19 patients

Routine HRCT imaging of chest in COVID-19 patient is NOT recommended

Nearly two-thirds of persons with asymptomatic COVID-19 have abnormalities on HRCT chest imaging which are nonspecific, and most of them do not progress clinically

HRCT imaging of chest done in first week of illness might often underestimate the extent of lung involvement, giving a false sense of security

Correlation between extent of lung involvement by HRCT imaging of chest and hypoxia is imperfect; often, young individuals with extensive lung involvement will not develop hypoxia, while elderly individuals with minimal/ less extensive lung involvement are likely to develop hypoxia

Radiation exposure due to repeated HRCT imaging may be associated with risk of cancer later in life HRCT imaging of chest NOT be done for following situations

Not to be done for diagnosing/screening Covid-19 infection (diagnosis of COVID-19 should be done only by using approved laboratory tests as recommended by ICMR)

Not indicated in asymptomatic and mild cases of COVID-19

Not needed to initiate treatment in COVID-19 patients with hypoxia and an abnormal chest radiograph

Not needed to assess response to treatment; more often, the lung lesions show radiological progression despite clinical improvement Indications for HRCT imaging of chest in COVID-19 patients

Suspected or confirmed cases of moderate COVID-19 who continue to deteriorate clinically even after initiation of appropriate therapy especially with high risk of invasive fungal infection In view of the above, treating pediatricians should exercise caution while advising HRCT imaging of chest

MUCORMYCOSIS guide

Mucormycosis is a serious fungal disease seen in patients with the underlying/predisposing factors such as immunosuppression, poorly controlled diabetes mellitus (especially diabetic ketoacidosis), misuse/overuse of steroids, cancer, organ/stem cell transplantation, and those under prolonged ICU treatment.

Mode of infection is usually through inhalation of fungal spores present in dust/air and it is not contagious; presentation is variable but usually occurs in third week after onset of COVID-19 symptoms

Signs and symptoms

Rhino-cerebral mucormycosis

o Facial pain, pain over sinuses, periorbital swelling

o Conjunctival injection or chemosis, blurring of vision/diplopia

o Paraesthesia/decreased sensation over half of face

o Blackish discolouration of skin over nasolabial groove/alae nasi; nasal crusting and nasal discharge which could be blackish, or blood tinged

o Loosening of teeth, pain in teeth and gums

o Discoloration (pale) of palate/turbinates insensitive to touch, eschar over palate

o Worsening of respiratory symptoms, haemoptysis, and chest pain; headache, alteration of consciousness and seizures etc.

Gastro-intestinal mucormycosis

o Symptoms and signs are very non-specific and mimic other gastrointestinal (GI) conditions but have a progressively worsening course

o Unexplained feed intolerance, abdominal distension, GI bleeding in a child with several risk factors (shock, vasopressors, broad-spectrum antibiotics)

o Persistent elevation of serum lactate in the absence of haemodynamic instability, liver dysfunction or other known causes

Diagnosis

KOH mount and microscopy, histopathology of debrided tissue – presence of ribbon like aseptate hyphae, 5-15 µ thick that branch at right angles

Positive serologic assays for Galactomannan or (1,3)-β-D-glucan also support the diagnosis of mucormycosis

Relevant radiological Investigations e.g. contrast enhanced CT of sinuses, CT chest for suspected pulmonary involvement (presence of more than 10 nodules, reverse halo sign, CT bronchus sign, pleural effusion – are highly suggestive of mucormycosis), MRI brain etc. to see the extent of systemic involvement; unstable patients might require repeat CT/MRI scans to assess the progression of disease

Management

Mucormycosis is an aggressive, life-threatening infection that needs a high index of suspicion, prompt diagnosis and early treatment (surgical debridement and antifungal therapy) by a multidisciplinary team to reduce mortality

Don’t wait for culture results to initiate therapy as mucormycosis is an emergency

Early complete surgical debridement is the cornerstone of treatment, and may be repeated as required

Conventional Amphotericin B (deoxycholate) as a prolonged IV infusion through a central venous catheter or PICC; closely monitor kidney function and electrolytes during treatment

o Reconstitute in water for injection, and dilute in 5% dextrose (do not use normal saline/Ringer’s lactate); start with test dose: 1 mg IV infusion over 20-30 min

o Loading dose: 0.25–0.5 mg/kg IV infused over 2-6 hours; gradually increase by 0.25 mg-increments/day to reach maintenance dose: 1–1.5 mg/kg/day

Liposomal Amphotericin B or Amphotericin lipid complex, if available; prolonged infusion over 2–3hours through a central venous catheter or PICC and closely monitoring KFT and electrolytes

o Reconstitute in water for injection, and dilute in 5% dextrose (do not use normal saline/Ringer’s lactate); start full dose from first day; 5 mg/kg/day (10 mg/kg/day in case of CNS involvement)

o Continue till a favourable response is achieved which may take 3-6 weeks following which step down to oral Posaconazole (delayed release tablets, children ≥3 years and adolescents ≤17 years: 5-7 mg/kg/dose twice daily on day 1, followed by 5 to 7 mg/kg/dose daily) or Isavuconazole (not approved below 18 years of age, however if required to be given, the dose for weight >30kg: 200 mg 1 tablet 3 times daily for 2 days followed by 200 mg daily, <30kg: half the dose for >30 kg children) may have to be taken for prolonged period as per advice of pediatrician

Posaconazole should be given as salvage therapy in cases who cannot be given Amphotericin B

o Injection IV

Children <11 years: loading dose: 7-12 mg/kg/dose IV twice on the first day and maintenance dose: 7-12 mg/kg IV once a day, starting on second day (max: 300 mg/dose)

Adolescents: 300 mg IV twice on the first day and maintenance dose 300 mg IV once a day, starting on the second day

o Oral delayed release tablets (100 mg) and Oral Suspension (for infants and smaller children) To be administered with fatty food:

o Oral delayed release tablets : Children 7 to 12 years: initial dose: 200 mg/dose thrice daily; maximum dose: 800 mg/day

Adolescents: 300 mg/dose twice on day 1, followed by 300 mg/dose once daily

o Oral suspension (for infants and children) as syrup in a strength of 40 mg/ml. The recommended dose for children with body weight <34 kg is 4.5 to 6 mg/kg/dose 4 times daily; maximum dose 800 mg/day. For those children and adolescents with body weights >34 kg the dose is 200 mg/dose 3 times daily (maximum 200 mg 4 times a day)

Treatment has to be continued until resolution of clinical signs and symptoms as well as radiological
signs of active disease; and may have to be given for quite a long period of time.

—Source: Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India

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