covid treatment in children

1. PAEDIATRIC COVID-19
CLINICAL PRESENTATION
AND
MANAGEMENT
Presenter:
Dr. Manish Tiwari,
Professor and H.O.D.,
Department of Paediatrics,
G.M.C., Gondia.
Acknowledgement:
Dr. L.S. Deshmukh,
Professor and H.O.D.,
Department of Neonatology,
G.M.C., Aurangabad.

2. OBJECTIVES ?
 To know the epidemiology of COVID 19 in children in
India.
 To understand the wide range of signs and
symptoms with which COVID 19 can manifest in
children .
 Classify children in various category as per
presentation.
 Management of COVID 19 and its complications in
children.
 Follow up care after discharge.
 Prevention and vaccination strategy.

3. WHY?
 In India children and young adults under 20
years of age account for 34.8 percent of the
total population.
 The next wave of COVID-19 in India .
 Though majority asymptomatic but
Multisystem Inflammatory Syndrome in
Children (MIS-C) .

4. CASE BURDEN?
 Among the confirmed cases of COVID-19 in India,
less than 12 percent were children and young
adults under the age of 20 years and 3-4 percent
were children under the age of 10 years.

5. BLINDSPOT?
 Data is only available on the proportion of
paediatric cases in the total confirmed cases
 No Data regarding specifications on clinical
presentations, hospitalization rates, severity of
disease, outcomes, MIS-C cases, or sero-
surveillance/outbreaks in children.
 No National Database.

6. KEY OBSERVATION WITH
AVAILABLE DATA
 Mortality rates amongst hospitalized COVID-19
positive children below the age of 10 years
(excluding neonates) was 2.4 percent
 About 40 percent of children who died had co-
morbidities
 Only 9 percent of all hospitalized COVID
positive children presented with severe illness,
under 10 years of age.

7. Types of COVID-19
presentation in children
 Neonatal Covid
 Acute Covid
 Post Covid

8. Case Definition -Neonate
● Suspected COVID-19 neonate
- Born to mother with a history of COVID-19 infection
between 14 days before and 28 days after delivery,
OR
- The newborn directly exposed to those infected with
COVID-19(including members, caregivers, medical staff,
and visitors).
● Confirmed COVID-19 neonate: RT-PCR positive

9. Potential modes of
transmission in Neonates

10. Neonatal manifestations
 History of exposure to a contact or infection in
mother are clues.
 Asymptomatic presentation in a major proportion
 Milder illness, and hastened recovery in infants
-- passive transfer of maternal IgG antibodies, and
- lower ACE-2 expression
- Immune system not developed.
 Symptomatic – three types of presentation

11. Clinical Presentation
Early onset
(onset of illness between 2 to 7 days after birth)

12. Clinical Presentation
late-onset neonatal COVID-19
(> 7 days)

13. Clinical Presentation
MIS-N

14. Investigations
 Blood Sugar, CBC, CRP, Blood Culture
 CXR
 D-dimer
 LFT, RFT
 Antibody levels in Mother & Baby
 If MIS suspicion: Use of ECG, ECHO and Pro-
BNP/Trop T
 Other inv. As per need. (ABG, Electrolytes, Ferritin,
IL6, LDH)

15. Treatment for severe Covid 19
in Newborn
 Need NICU Care
 Use of Incubator preferable
 Babies with Pneumonia
– Appropriate Respiratory support
- May use IV Steroids (Dexa/MPS)
- No recommendation of Remdesivir
-If d-Dimer is raised, ?use of heparin/enoxaparin
with caution
- No role of plasma
 If features/suspicion of MIS, IVIG may be used.

16. Covid Pneumonia : Respiratory
support
 Mild respiratory distress: nasal canula oxygen
 Non-invasive ventilation (NIV) as first line - CPAP is
preferred
 High flow nasal cannula (HFNC) as per availability
 Early intubation and mechanical ventilation should be
considered.
 Endotracheal intubation - by a skilled person.

17. OXYGEN HOOD

18. NASAL PRONGS

19. VENTURI MASK

20. NON REBREATHING MASK

21. CPAP

22. BI-PAP

23. LARYNGOSCOPE AND
TUBE

24. Discharge Policy
 COVID 19 Positive newborns-
 Asymptomatic or mild/moderate clinical course-
Discharge after 10 days without repeating RT PCR
 Severe cases- Document single negative RT PCR
after resolution of symptoms
 Asymptomatic neonates- RTPCR Negative
 If mother stable: discharge with mother
 If mother is sick: discharged with care taker at 24-
48 hrs

25. DISEASE SPECTRUM OF
COVID INFECTION IN
CHILDREN:
Children with suspected COVID-19 to be
kept together with caregivers where
possible.
Confirm COVID-19 before determining severity.
Some children may present with symptoms of
acute abdomen or other GI symptoms or rarely
CNS symptoms.

27. Mild Disease
o Home isolation.
o Supportive care; monitoring at home.
o Adequate hydration and feeding.
o Paracetamol 10-15 mg/kg/dose for fever.
o Use MDI and spacer if any inhaled medications
indicated. Avoid nebulization.
o No role of any blood investigation & Imaging.

28. Parents to report if worsening of symptoms (Danger
signs)
 Persistent fever for ≥ 5 days.
 Recurrence of fever.
 Reduction in oral intake.
 Dehydration
 Decreased urine output
 Lethargy
 Shortness of breath
 SpO2<94%.

29. Children with Co- morbidities
 If home monitoring/ isolation not possible, admit children with
mild illness particularly those with co- morbidities such as
 Chronic lung disease
 Symptomatic heart disease
 Chronic kidney disease
 Neurological disorder
 Malignancies on chemotherapy
 Diabetes
 Morbid obesity
 Immunodeficiency, or on immunosuppressants due to pre-
existing conditions etc.

30. Duration of home isolation
 10 days after symptom onset and no fever for 3
days. [This is followed by further 7 days of
home isolation and self monitoring]
 Documentation of negative RT-PCR/
CBNAAT no longer recommended

31. Moderate disease
ADMIT IN DEDICATED COVID FACILITY
 Supportive care: Adequate hydration and feeding
(may need nasogastric feeding), ORS (avoid
dehydration and overhydration), monitor vitals.
 Symptomatic care: Paracetamol 10-15 mg/kg/dose
for fever (minimum 4 hours gap between two doses),
 Children who have wheezing use Salbutamol ±
Ipratropium MDI +Spacer
 Avoid Nebulisation

32. Moderate disease
Supportive/Specific Therapy
 Oral antibiotics- only if bacterial infection suspected.
 If SpO2<94%, start supplemental oxygen therapy
 Consider steroids:
If there is very rapid progression and when other causes of fever
are ruled out,
OR
If saturation is below 94% on supplemental oxygen therapy
beyond 5 days of illness,
OR
Fever persisting beyond 7 days with high inflammatory markers.
 Watch for progression to severe disease.

33. Severe disease
Admit in COVID HDU/ PICU
 Supportive care: Maintain adequate hydration
(avoid over hydration). Start early enteral
feeding. Monitor vitals.
 Symptomatic Care Paracetamol 10-15
mg/kg/dose through NG tube or IV for fever;

34. Severe disease
 Supportive/Specific Therapy
 Empiric antimicrobials
 Oxygen therapy:
 Start with NRBM (10 L/min); if no response
 Step-up to HFNC with a flow of 0.5 to 2 L/kg/min and FiO2 of
40%- 100% to target SpO2 92 to 96% and then titrate
according to response.
 If no response – step up to NIV. SpO2 target > 94% during
resuscitation (once stable, target SpO2> 90%).
 Awake proning in children >8 years.

35. Severe Disease
Steroids:
 Dexamethasone 0.15 mg/kg per dose (max. 6 mg) for 1-2
times a day, 5 days (duration may be extended up to 10
days depending on clinical response) is preferred.
 Alternatively, Prednisone (1–2 mg/kg/day per dose,
maximum dose 60 mg) or Methylprednisolone (1–2
mg/kg/day IV, maximum dose 60 mg) can be used.
 Evaluate for thrombosis, HLH, organ failure.

36. Management of ARDS
 Elective intubation if GCS persistently below 8/ refractory
shock
 Conservative fluid management strategy, sedation. Oxygen
therapy/ respiratory support:
 Mild ARDS: HFNC/NIV initially
 Severe ARDS: Mechanical ventilation: Low tidal volume (6
ml/kg), high PEEP, cuffed endotracheal tube.
 Prone if feasible. If poor response, consider HFOV, ECMO.

37. Management of shock/
myocardial dysfunction
 Crystalloid bolus 10-20 ml/kg over 30-60
min; to be administered fast if child is
hypotensive, while monitoring closely.
Avoid/ administer carefully if myocardial
dysfunction suspected.
 Monitor for fluid overload.
 Early inotrope support- epinephrine first-
line treatment

38. Drugs used for COVID-19
 Anticoagulants (LMWH) are not recommended for
prophylaxis in any disease severity. It should be used
only for establishedthrombosis.
 Favipiravir, Remdesivir, Tocilizumab,
Hydroxychloroquine, Chloroquine, Ivermectin,
Azithromycin and Lopinavir/ ritonavir are not
recommended for routine use in COVID-19 in
children with any diseaseseverity.
 None of the drugs including Ivermectin,
Hydroxychloroquine have any role in prophylaxis.

39. Discharge Criteria
 Minimum after 10 days of symptom onset,
AND
 Clinical resolution of symptoms,
AND
 SpO2 > 95%, off oxygen for 3 days
 Followed by home isolation and self-monitoring for
7 days

40. Diagnostic Criteria for MIS-C [WHO]:
 Children and adolescents 0–19 years of age with fever ≥ 3 days
AND two of these:
 Rash or bilateral non-purulent conjunctivitis or muco- cutaneous
inflammation signs (oral, hands or feet).
 Hypotension or shock.
 Features of myocardial dysfunction, pericarditis, valvulitis, or coronary
abnormalities (including ECHO findings or elevated Troponin/NT-pro
BNP),
 Evidence of coagulopathy (elevated PT, PTT, elevated d- Dimers).
 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 COVID-19 (RT-PCR, antigen test or serology positive), or
likely contact with patients with COVID-19.

41. Evaluation of MIS-C
All of the
following:
1. Unremitting
Fever
> 38 C
1. Epidemiologi
cal Link to
SARS-CoV-2
2. Clinical
features
suggestive
of MIS-C
Yes
If no alternate
etiology, are
shock/life-
threatening
manifestations
present?
Yes
Simultaneous Tier 1
and 2 test
No
Tier 1
evaluation
Tier 2
evaluation
Evaluate for alternate
diagnosis
Monitor for features
of MIS-C
No
Negative
Screen
Positive
Screen

42. Investigations
Tier 1:
SARS-CoV-2 PCR and serology AND
Both of the following should be present:
 CRP> 5 mg/L and/or ESR > 40 mm in the first hour.
 At least one of these:
◦ ALC < 1000/µL,
◦ Platelet < 150,000/µL,
◦ Na < 135 mEq/L,
◦ Neutrophilia (ANC>7700/µL),
◦ Hypoalbuminemia (<3 g/dL)

43. Tier 2:
Cardiac
 ECG
 Echocardiogram
 Pro BNP (>400 pg/mL)
 Elevated Troponin T
Inflammatory markers
 Raised Procalcitonin,
 Ferritin (>500 ng/ml),
Coagulopathy
 Prolonged PT or PTT,
 D-dimer (>0.55 mg/L),
 Fibrinogen(>400 mg/dL),
Other
 High LDH,
 Triglyceride,
 IL-6
 Blood Smear.

44. MILD (Non-life threatening)
MIS-C
Fever and stable vital signs. Absence of shock or organ
threatening disease.
 IV Methylprednisolone (1-2 mg/kg day) for 3 days
followed by course of oral steroids tapered over 2–3-
week.
 For thromboprophylaxis Aspirin 3 - 5 mg/kg/day; max 75
mg/day (contraindication- platelets <80,000/ µL or active
bleeding)
 If no improvement or worsening of symptoms
 Consider IVIG after ruling out alternative diagnoses.

45. SEVERE MIS-C/ Myocardial/
coronary involvement
 Shock, respiratory distress, MOD, cardiac
manifestations (myocardial dysfunction/ coronary
abnormalities).
 IVIG + IVMP
 IVMP - (Methylprednisolone 1-2 mg/kg/d) and
 IVIG (2 g/kg within 12-24 hrs; Slower
administration may be needed in patients with
cardiac failure/ fluid overload)
 Antimicrobials- based on clinical judgement
and microbiological data if child presents
with shock.

46.  If no improvement or worsening of symptoms,
 Methylprednisolone 10-30 mg/kg/day for 3-5 days, max 1
g / day).
 If unresponsive to above, may consider high dose
Infliximab for < 5 years with Kawasaki like illness.
 Consult an expert for further therapy e.g.: Anakinra
 Taper steroids over 2-3 weeks while monitoring
inflammatory markers (CRP).
 Early vasoactive medication in children with shock/
myocardial dysfunction.
 Cautious fluid resuscitation

47.  Antiplatelet and anticoagulation therapy (in patients without
active bleeding or significant bleeding risk):
 Aspirin 3 - 5 mg/kg/day; max 75 mg/day (Indications: KD like
features; coronary artery Z score>=2.5; thrombocytosis;
contraindication- platelets <80,000/ µL)
 Enoxaparin (indications: Coronary aneurysm (Z-score > 10)
or Thrombosis or LVEF < 35%) Dosage: 1 mg/kg twice daily
SC.

48. Discharge criteria
 Afebrile for more than 3 days
AND,
 CRP, ferritin, and d-dimer improving or below the MIS-C
thresholds,
 Blood cultures sterile,
 ECG without arrhythmia,
 Tolerating oral feeds,
 Not requiring supplemental oxygen.
Ensure adequate follow ups:
 Paediatric review: one week (repeat CBC, CRP, and others,
if not normalized prior to discharge)

49. Cardiac specific
recommendations
 ECG repeated 48 hourly
 Echo repeated at 7-14 days and 4-6 weeks
 Repeat at 1 year if initial echo is abnormal
 Optional- Cardiac MRI at 2-6 months (if
initially LVEF < 50%

50. Post Covid Care
 Isolation for 15 days from first symptoms
 Remain at home for 3 weeks
 Follow Covid Appropriate Behaviour
 Wear Mask and Social Distancing
 Healthy Diet
 Regularly Exercise specially in adolescence
 Plenty of Fluids
 Checking saturation twice daily for 10 days in co-
morbid patients

51. Post Covid Care
Look for following symptoms till 3 months / Early
Diagnosis of MIS
 Recurrance of High grade fever / persisstance cough
 Rash over body
 Redness of eyes
 Severe weakness
 Pain in Abdomen with or without Loose motions / vomiting
 Any abnormal symptoms / sign / mental changes /
behavior.

52. THANK YOU.