Covid-19 Infection in children

1. COVID-19 Infection in Children
Dr. Vinit Warthe
Professor and Head
Department of Pediatrics
Government Medical College, Akola
30-Mar-20

2. Coronaviruses
• Coronaviruses are RNA viruses with glycoprotein spikes that give
them a crown like appearance.
• Four species have been in circulation for a long time and cause mild
respiratory disease.
• They have a lot of genetic diversity and have jumped the species
barrier leading to severe respiratory disease (SARS virus in 2002-2003
and the MERS virus in 2012-2013). In December 2019, a novel
coronavirus emerged in Wuhan City of Hubei Province; this was later
termed as SARS-CoV-2 or COVID-19.

3. Spread of infection
• Spreads by droplets from infected people during sneezing & coughing.
• Large droplets that travel for 1-2 m. Settle on surfaces on which they
remain alive for hours or days.
• Infected person can also spread the infection even before the onset of
symptoms. Infection is acquired by either inhalation of infected droplets or
touching surfaces/ fomites contaminated with the infected droplets and
then touching the eyes, nose and mouth.
• Incubation period varies from 2-14 days.
• The average number of people infected by one infected individual is
between 2-3.

4. COVID-19 in children
• Mostly middle aged (>30 years) and elderly.
• Symptomatic infection in children appears to be uncommon, and
when it occurs, it is usually mild.
• No significant gender difference in children
• Most infected children recover one to two weeks after the onset of
symptoms.
• According to the recent report of the China-WHO Joint Mission Expert
Group, the current domestic case data show that children under 18
years of age account for 2.4% of all reported cases, and no deaths
reported.

5. Infants
• About 4% of children were asymptomatic, 51% had mild illness and
39% had moderate illness. About 6% had severe or critical illness,
compared to 18.5% of adults.
• The study also found infants had higher rates of serious illness than
older children.11% of infants had severe or critical cases compared to
7% of children ages 1-5, 4% of those 6-10, 4% of those 11-15 and 3%
of those 16 and older.
• In Dong Y, et al study -2143 pediatric patients included in this study,
only one child died
Dong Y, et al. Pediatrics. March 16, 2020, http://bit.ly/33ljvcy

6. Pediatric data
Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an
observational cohort study.Haiyan Qiu*, Junhua Wu*, Liang Hong, Yunling Luo, Qifa Song, Dong Chen Lancet 25 March
2020

7. Probable reasons Why COVID-19 is less
affected in children
• The time period of the outbreak, is the winter vacation time of the
university, middle school and kindergarten. It is a good time to avoid
the collective cluster disease by chance.
• Secondly, humoral and cellular immune development in children is
not fully developed.
• This may be one of the mechanisms that lead to the absence of
severe immune responses after viral infection

8. Probable reasons Why COVID-19 is less
affected in children
• As COVID-19 virus exploits the ACE2 receptors to gain entry inside the
cells, under expression, immaturity of ACE2 receptors in children is
another hypothesis in this regard.
• Recurrent exposure to viruses like respiratory syncytial virus in
winters can induce more immunoglobulins levels against the new
virus infection compare to adults.
• There is no direct evidence of vertical mother-to-child transmission,
but newborns can be infected through close contact.

9. Clinical features in Adults
• In a study describing 1099 patients with COVID-19 pneumonia in Wuhan,
the most common clinical features at the onset of illness were:
• Fever in 88%
• Dry cough in 67%
• Fatigue in 38%
• Myalgias in 14.9%
• Dyspnea in 18.7%
• Pneumonia appears to be the most common and severe manifestation of
infection. In this group of patients breathing difficulty developed after a
median of five days of illness.
• Acute respiratory distress syndrome developed in 3.4% of patients.

10. Clinical features in Children
Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an
observational cohort study.Haiyan Qiu*, Junhua Wu*, Liang Hong, Yunling Luo, Qifa Song, Dong Chen Lancet 25 March
2020

11. Clinical features in Children
• The symptoms of COVID-19 are similar in children and adults
• However, children with confirmed COVID-19 have generally
presented with mild symptoms and usually recover within 1 to 2
weeks.
• Reported symptoms in children may include cold-like symptoms, such
as fever, dry cough, sore throat, runny nose, and sneezing.
Gastrointestinal manifestations including vomiting and diarrhea.
• Children with underlying medical conditions and special healthcare
needs may be at higher risk for severe illness.

12. Red Flag
• Mild or Asymptomatic illness in
children is a big variable
because we know
asymptomatic shedding is
actually probably more likely to
sustain an epidemic within a
population
• So social distancing measures
may really be the way to keep
that from happening.

13. Investigations
• White Blood Cell Count
-Leukopenia, leukocytosis, and lymphopenia have been reported.
However thrombocytopenia is considered as a poor prognostic sign.
• INFLAMMATORY MARKERS
-Serum Procalcitonin
Serum procalcitonin is often normal at the time of admission; however it
increases in patients who require ICU care. In one study high D-Dimer and
lymphopenia are associated with poor prognosis.
-CRP
CRP levels are raised. Tracks with disease severity and prognosis.
In patients suffering from with severe respiratory failure with a normal CRP level
an alternative diagnosis should always be sought.

14. Other laboratory findings
• Some children have increased liver enzymes, lactate dehydrogenase
(LDH), muscle enzymes, and myoglobin;
• Some critically ill patients have increased troponin, D-dimer and
ferritin and the number of peripheral blood lymphocytes have
progressively reduced.
• Like adults, the children with severe and critical illness may be
accompanied by elevated levels of inflammatory factors such as
interleukin (IL)-6, IL-4, IL-10, and tumor necrosis factor (TNF)-α

15. Radiology
• There are no abnormal findings in the early stages of the disease in
the children’s plain X-rays with COVID-19 thus plain X-rays it is not
recommended especially in the early stages and in whom without
symptoms or any positive risk factors. Findings are most extensive
about 10-12 days after symptom onset.
Evolution in 1-2 weeksbilateral and peripheral
alveolar consolidation COVID-19 pneumonia

16. Chest CT
Suspected cases should undergo chest CT examination as soon as
possible.
• The most important finding in early stages is a single or multiple
limited ground-glass opacity which mostly located under the pleura or
near the bronchial blood vessel bundle especially in the lower lobes.
• Also compared to adults, consolidation with surrounding halo signs is
more common in pediatric patients and was suggested as a typical
sign in pediatric patients.

18. DIAGNOSTIC MODALITY FOR COVID-19
• SARS-CoV-2 RNA is detected by polymerase chain reaction (RT-PCR)
• A single positive test should be confirmed by a second RT-PCR assay
targeting a different SARS-CoV-2 gene
Rapid tests
• COVID-19 Rapid Test qualitatively detects IgG and IgM antibodies to
SARS-CoV-2
• The IgM-IgG combined assay has better utility and sensitivity
compared with a single IgM or IgG test. It can be used for the rapid
screening of SARS-CoV-2 carriers, symptomatic or asymptomatic

19. Mild Disease
• Upper respiratory symptoms (eg, pharyngeal congestion, sore throat,
and fever) for a short duration or asymptomatic infection
• Positive RT-PCR test for SARS-CoV-2
• No abnormal radiographic and septic presentation

20. Moderate disease
• Mild pneumonia
• Symptoms such as fever, cough, fatigue, headache, and myalgia
• No complications and manifestations related to severe conditions.

21. Severe disease
• Mild or moderate clinical features, plus any manifestations that suggest
disease progression:
• Rapid breath (≥60 breaths per min for 0-2 mths; ≥50 breaths per min for
infants 2 mths to 11 months; ≥40 breaths per min for aged 1 yr to 5 years)
• Hypoxia (SpO2- <93%, PaO2/FiO2 <300)
• Lung infiltrates >50% within 24- 48 hours
• Lack of consciousness, depression, coma, convulsions
• Dehydration, difficulty feeding, gastrointestinal dysfunction
• Myocardial injury
• Elevated liver enzymes
• Coagulation dysfunction, rhabdomyolysis, and any other manifestations
suggesting injuries to vital organs

22. Critical illness
• Rapid disease progression, plus any other conditions:
• Respiratory failure with need for mechanical ventilation (eg, ARDS,
persistent hypoxia that cannot be alleviated by inhalation through
nasal catheters or masks)
• Septic shock
• Organ failure that needs monitoring in the ICU

23. At the moment, the therapeutic
strategies to deal with the infection
are only supportive, and prevention
aimed at reducing transmission in the
community is our best weapon.

24. Treatment
• There is no specific antiviral treatment recommended for COVID-19,
and no vaccine is currently available.
• No drug of choice
• Oxygen support
• Oxygen saturation to be maintained above 90%
• Conservative fluid management
• Give empirical antibiotics
• High dependency / ICU care when needed

25. Treatment
• The vast majority of patients will do fine without any therapy, so in
most cases there's no need for antiviral therapy.
• However, waiting until patients are severely ill before initiating
therapy could cause us to miss an early treatment window, during
which the disease course is more modifiable.
• Predictors of adverse outcome might be useful in predicting who will
do poorly and thus who might benefit most from early anti-viral
therapy, but data is limited.

26. Lopinavir/Ritonavir
• In vitro reduces replication by 50% in MERS corona virus
• Definite efficacy not proven
• WHO has mentioned as an agent that can be tried
• May be also tried in combination with Interferon alpha or Ribavirin
• Potent CYP3A4 inhibitor – monitor for drug interactions
• Oral and liquid formulation is available
• Dose: Adult: 400/100mg PO Q12h

27. Lopinavir/ritonavir combination
• Pediatric (lopinavir/ritonavir combination): Oral solution
• 14 days to 6 months old: based on lopinavir 16 mg/kg/dose PO 12
hourly orally
• Oral tablet
• 15-25kg: LPV/r (200 mg/50 mg) per DOSE q12h PO
• 26-35 kg: LPV/r (300 mg/75 mg) per DOSE q12h PO
• > 35 kg : LPV/r (400 mg/100 mg) per DOSE q12h PO
(In Adults for 14 days / Pediatric data not available. A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19
Bin Cao, M.D.,Yeming Wang, M.D. et all,NEJM, March 18,2020)

28. Oseltamivir
• Neuraminidase enzyme inhibitor in influenza
• Not seen in SARS CoV2
• No trials on COVID-19
• Many patients with similar presentation of COVID 19 might be
influenza
• Hence better to give the drug to avoid patient worsening due to
influenza
• Dose: 150mg BD x 5 days

29. Oseltamivir
• < 3 months: 12 mg (per dose) PO 12 hourly for 5 days
• 3-5 months: 20 mg (per dose) PO 12 hourly for 5 days
• 6-11 months: 25 mg (per dose) PO 12 hourly for 5 days
• Age ≥ 1 year
• < 15 kg: 30 mg (per dose) PO 12 hourly for 5 days
• 15-23 kg: 45 mg (per dose) PO 12 hourly for 5 days
• 23-40 kg: 60 mg (per dose) PO 12 hourly for 5 days
• >40 kg: As in adults 75 mg capsule (per dose) PO 12 hourly for 5 days

30. CHLOROQUINE/HYDROXYCHLOROQUINE
• Proposed mechanism- Hampers the low pH dependent steps of viral
replication
• No renal or hepatic dose adjustments necessary
• Proposed for prophylaxis- however lacks evidence. Side effects: QT
prolongation
• Dose (Adult) : 400mg PO Q12h x 1 day, 200mg PO Q12h x 4 days
• Pediatric: 10mg of base/kg/DOSE PO q12h x 1 day (max 600mg), then
3mg/kg/DOSE TID x 3 days (maximum 200mg/dose)
(Each 250 mg tablet of chloroquine phosphate is equivalent to 150 mg base.
One tablet of 200 mg of hydroxychloroquine is equivalent to 155 mg base)
• Contraindications-Hypersensitivity to chloroquine, the presence of retinal or
visual field changes of any etiology

31. CORTICOSTEROIDS
• Not indicated in treating SARS CoV2 as per available evidence
• Might prolong viral shedding
• Use as per indicated in septic shock/if patient has other indications
for steroid use

32. ASCORBIC ACID
• Ascorbic acid did appear to improve mortality in the multi-center
CITRIS-ALI trial.
• Extremely limited evidence suggests that ascorbic acid could be
beneficial in animal models of corona virus (Atherton 1978).
• Administration of a moderate dose of IV vitamin C could be
considered
• No high-quality evidence to support ascorbic acid in viral pneumonia.

33. ANTI BACTERIAL THERAPY
• Initial empirical antibiotics
• COVID-19 itself is not an indication to start antibiotics.
• However antibiotics can be initiated to treat secondary bacterial
pneumonia.
• Broad spectrum antibiotics to be initiated according to the institution
based guidelines.
• Bacterial pneumonia can emerge during the hospital course
(especially ventilator associated pneumonia in patients who are
intubated).

34. Cured Patient
• Cured outcome referred to normal body temperature for 3 days, plus
improved outcomes and two negative results on RT-PCR for SARS-
CoV-2.

35. Approved by Public health services
of Maharashtra
Grand Medical college and Sir JJ Groups of Hospitals
COVID-19 Management protocols for pediatric
patients

36. COVID 19 Suspect case
Any patient with ARI (fever with at least one of the following –cough and shortness
of breath) with
• History of travel risk COVID-19 affected countries in last 15 days or
• Close contact with a laboratory confirmed cases of COviD-19 in 14 days
• Home quarantine
• Temperature
Monitoring twice
• Contact and droplet
precautions
• Don’t need testing
• Don’t need admission
-CBC, ECG to be done or not to be
decided by Pediatrician
- Oseltamivir to be used in high risk
influenza suspect
- Do not combine Hydroxycholroquine
with Azithromycin
Mild Cases Moderate to Severe Cases

37. Mild cases
• Low grade fever, malaise,
rhinorrhea, sore throat
without shortness of breath
• Treatment- Oseltanivir
- Antibiotics if needed
( Azithromycin / Amoxclav)
Negative Test- Treat symptomatic
Positive Test
• Home isolation ( if > 72 hours afebrile
or 7 days after symptom onset
whichever is longer) Two negative
sample apart
• Monitoring of temperature
• Symptomatic treatment
• Contact and droplet precautions
• Danger signs explained
• High risk individuals may be
considered for admission based on
clinical judgement.
Confirmed case-A person with laboratory confirmation
of virus causing COVID-19 infection, irrespective of
clinical signs and symptoms

38. Moderate to Severe Cases:
• Rapid breath (≥60 breaths per min for 0-2 mths;
≥50 breaths per min for infants 2 mths to 11
mths; ≥40 breaths per min for aged 1 yr to 5 yrs)
• Hypoxia( SpO2 < 94 % in room air)
• Lack of consciousness, depression, coma,
convulsions
• Dehydration, difficulty feeding, GI dysfunction
• Hypotension (BP< less than 5th centile or > 2 SD
below normal for age)
• Myocardial injury
• Elevated liver enzymes
• Coagulation dysfunction, rhabdomyolysis, and
any other manifestations suggesting injuries to
vital organs
-Oxygen
-Antipyrectics
-MDI/ Nebulization
-Hypdroxychoroquine
-Lopinavir/Ritonavir
consideration of case to
case basis ( within 10 days
of symptoms)
-Corticosteroids to be
avoided
Negative test-
Treat according to case
• Azithromycin 10 mg/kg/dose
for 5 days can be considered
in confirmed cases

39. Severe cases
• NIV/ HFNC
• Ventilator management
• Prone ventilation/ECMO for refractory
hypoxemia
• Conservative fluid management if
patient not in shock
• Avoid disconnecting patients from
ventilators as it results in loss of PEEP ( In
line catheter for suction and clamp
endotracheal tube if disconnection
required )
Discharge- If two negative samples at 24 hours apart & Radiologic improvement
If worsening
• Respiratory Failure
• Hypotension
• Worsening mental status
• MODS
Shift to PICU

40. Newborn care in COVID-19

41. Newborns and COVID-19
• In February a Chinese newborn was diagnosed with the new
coronavirus just 30 hours after birth. The baby's mother tested
positive before she gave birth. It is unclear how the disease was
transmitted - in the womb, or after birth.
• Recently in London another newborn was tested positive for the
coronavirus, marking what appears to be the second such case as the
pandemic worsens.
• There was no evidence of vertical transmission of the infection from
mother to fetus/neonate.
• The virus was not detected in expressed breastmilk either.

42. Recommendations for neonatal resuscitation:
• Resuscitation of neonate can be done in a physically separate adjacent
room. If not feasible, the resuscitation warmer should be physically
separated from the mother’s delivery area by a distance of at least 2 m.
• Minimum number of personnel should attend and wear a full set of
personal protective equipment including N95 mask.
• Mother should perform hand hygiene and wear triple layer mask.
• The umbilical cord should be clamped promptly and skin-to-skin contact
avoided.
• Delivery team member should bring over the neonate to the
resuscitation area for assessment by the neonatal team.
• Follow standard NRP guidelines. If positive-pressure ventilation is
needed, self-inflating bag and mask may be preferred over T-piece
resuscitator

43. Stable Neonates
• Stable neonates exposed to COVID-19 infection from mothers or
other relatives should be roomed-in with their mothers and be
exclusively breastfed.
• If rooming-in is not possible because of the sickness in the neonate or
the mother
-the neonate should be fed expressed breast milk of the mother by a
nurse or family member who has not been in contact with the mother
or other suspected/proven case

44. • Healthy neonate may be roomed-in with mother. The mother-baby
dyad must be isolated from other suspected and infected cases and
healthy uninfected mothers and neonates.
• Direct breastfeeding can be given. Mother should wash hands
frequently including before breastfeeding and wear mask. If not
feasible due to maternal or neonatal condition, expressed breast milk
can be fed.
• If safe, early discharge to home followed by telephonic follow-up or
home visit by a designated nurse may be considered
Scenario 1: Resources for isolation of normal, suspected to be infected
and infected mothers not available OR healthcare facilities are
overwhelmed because of large number of COVID-19 infections OR
evidence of community spread is present.

45. Scenario 2: If resources for isolation of normal, suspected to be
infected and infected mothers can be made available AND there is no
evidence of community spread
• Isolate Neonate from the mother.
• During isolation, healthy neonates should preferably be cared for by family
member not in contact with mother or other suspected/proven case.
• If safe, while mother is in isolation early discharge to home with healthy
family member followed by telephonic follow-up or home visit by a
designated nurse may be considered.
• Mother can express milk after washing hands and breasts and while
wearing mask. This expressed milk can be fed to her own baby without
pasteurization.
• Mother and baby can be roomed-in once mother is tested negative.
• Viral testing in mothers with suspected infection should be conducted and
reported on priority.

46. Neonates with suspected/proven COVID-19
• Respiratory support for neonates with suspected/proven COVID-19
infection is guided by principles of lung protective strategy including
use of non-invasive ventilation.
• NIPPV and High Flow Nasal cannulas should preferably be avoided.
• Antivirals or chloroquine/Hydroxychloroquine / Systemic
corticosteroids and intravenous gamma globulin– are NOT
recommended in symptomatic neonates with confirmed or suspected
COVID-19.

47. Cleaning
• 0.5% sodium hypochlorite (equivalent to 5000 ppm) can be used to
disinfect large surfaces like floors and walls at least once per shift and
for cleaning after a patient is transferred out of the area.
• 70% ethyl alcohol can be used to disinfect small areas between uses,
such as reusable dedicated equipment.
• Hydrogen peroxide (dilute 100 ml of H2O2 10% v/v solution with 900
ml of distilled water) can be used for surface cleaning of incubators,
open care systems, infusion pumps, weighing scales, standby
equipment ventilators, monitors, phototherapy units, and shelves.
Use H2O2 only when equipment is not being used for the patient.
Contact period of 1 hour is needed for efficacy of H2O2

48. Visitors Policy
• Persons (including parents) with suspected or confirmed COVID-19
infection should not be allowed entry in the childbirth/neonatal care
area where care to mother/sick neonates is being provided.
• For neonates roomed in with mother for suspect/confirmed COVID-
19 infection, one healthy family member following contact and
droplet precautions should be allowed to stay with her to assist in
baby care activities.

49. Discharge
• Stable neonates exposed to COVID19 and being roomed-in with their
mothers may be discharged together at time of mothers’ discharge.
• Stable neonates in whom rooming-in is not possible because of the
sickness in the mother and are being cared by a trained family
member may be discharged from the facility by 24-48 hours of age.

50. Immunization in Neonate
• Follow routine immunization policy in healthy neonates born to
mothers with suspected/proven COVID-19 infection.
• In neonates with suspected/proven infection, vaccination should be
completed before discharge from the hospital as per existing policy.

51. Consent
•All available treatment protocols are only
recommendations so its better to take informed
consent from patient/parents/guardians.

52. References
• Clinical and epidemiological features of 36 children with coronavirus disease 2019
(COVID-19) in Zhejiang, China: an observational cohort study.Haiyan Qiu*, Junhua
Wu*, Liang Hong, Yunling Luo, Qifa Song, Dong Chen Lancet 25 March 2020
• INTERNATIONAL PULMONOLOGIST’S CONSENSUS ON COVID-19Chief Editors Dr.
Tinku Joseph (India), Dr. Mohammed Ashkan (Iran)
• Perinatal-Neonatal management of COVID-19 infection ,26 March 2020. FOGSI,
NNF, IAP India
• A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19 Bin Cao,
M.D.,Yeming Wang, M.D. et all, NEJM, March 18,2020)
• Dong Y, et al. Pediatrics. March 16, 2020, http://bit.ly/33ljvcy
• Grand Medical college and Sir JJ Groups of Hospitals COVID-19 Management
protocols for Pediatric patients
• Xray Case courtesy of Dr Fabio Macori, <href="https://radiopaedia.org/
">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.
org/cases/74867">rID: 74867</a>

53. Thank you