covid19 in children

1. Dr.KhalidHamasalih
Ass.prof.ofPediatrics
M.B.Ch.D.C.H F.I.B.M.S.ped
Universityofsulaimany
Collegeofmedicine
Pediatricsdepartment
Pediatrics COVID-19

2. What was The story ?
1920 domesticated chickens
1931 new respiratory
infection of chickens
1933 IBV
1937 Cultivated
1940 Murine
enceph,mouse hepatitis
1960 human
2003 SARS-CoV
2013 MERS-CoV
2019 SARSCOV2 page 2

3. Contoso
Pharmaceuticals
Copyrights apply
Covid19

4. Phylogenetictreeofcoronaviruses[
page 4

5. • COVID-19
page 5
B.1.1.7 variant
was first
detected in the
United
Kingdom in late
summer 2020
B.1.351 lineage – This
variant, also known as
20H/501Y.V2, was
identified in South
Africa in late 2020
G614
polymorphism
The G614 variant
did not appear to
be associated with
a higher risk of
hospitalization
P.1 lineage – This
variant, also
known as
20J/501Y.V3, was
first identified in
Japan in four
travelers from
Brazil
What are
virus
variants?

6. ProposedRoutesofSARS-CoV-2Transmission
Galbadage. Front Public Health. 2020;8:163. WHO. Scientific Brief. July 9, 2020. Slide credit: clinicaloptions.com
SARS-CoV-2–
Infected Host
Susceptible
Host
Aerosols
< 5 µm diameter
Suspended in air
Contact/Droplet
> 5 µm diameter
Direct contact
or
< 1 meter distance
Fomites (?)
Environmental
Stability
Points of entry:
Eyes, nose, or
mouth
Airborne (?)
> 1 meter distance
Urine/feces:
RNA found in
both; live virus
cultivated from
few specimens

7. page 7
the age distribution was as follows
● <1 month – 7%
● 1 month to 1 year – 22 %
● 1 to 2 years – 10 %
● 2 to 5 years – 11 %
● 5 to 10 years – 16 %
● >10 years through 18 years -34 %

8. What is the incubation period forCOVID-19?
• The incubation period for COVID-19 is thought to be within 14 days
following exposure, with most cases occurring approximately four to
five days after exposure.
page 8

9. page 9
Clinical
Spectrum
Severe Illness:
Individuals who have
low SpO2<90% ,>30
breaths/min, or lung
infiltrates >50%.
14%
Asymptomatic or
Presymptomatic
Infection
33 %
Mild Illness: various signs
and symptoms of COVID-
19 (e.g., fever, cough, sore
throat, malaise, headache,
muscle pain, nausea,
vomiting, diarrhea, loss of
taste and smell
Moderate Illness: Individuals
who show evidence of lower
respiratory disease during
clinical assessment or imaging
and who have saturation of
oxygen (SpO2 ) ≥94% on room
air at sea level.
Critical Illness who
have respiratory failure,
septic shock, and/or
multiple organ
dysfunction
5 %.

10. PrimarySymptomsofCOVID-19
Li. J Med Virol. 2020;92:577.
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html Slide credit: clinicaloptions.com
Headache
Congestion or runny nose,
new loss of taste or smell
Fatigue, muscle
or body aches,
fever or chills
Nausea or
vomiting, diarrhea
Cough, sore throat
Shortness of breath
or difficulty breathing
“Symptoms may
appear 2-14 days
after exposure to
the virus”

11. CLINICAL MANIFESTATIONS
# Among children age (0-9 years) , the frequency of symptoms was as follows:
● Fever, cough, or shortness of breath– 63 percent
• Fever – 46 percent
• Cough – 37 percent
• Shortness of breath – 7 percent
● Myalgia – 10 percent
● Rhinorrhea – 7 percent
● Sore throat – 13 percent
● Headache – 15 percent
● Nausea/vomiting– 10 percent
● Abdominal pain – 7 percent
● Diarrhea – 14 percent
● Loss of smell or taste – 1 percent
page 11

12. Complicationorexrtapulmpresentation
page 12

13. COMPLICATIONSANDASSOCIATEDSYNDROMES
• What are the most common dermatologic syndromes associated with COVID-19?
• an exanthematous (morbilliform) rash, pernio-like acral lesions, livedo-like lesions, retiform purpura,
necrotic vascular lesions, urticaria, vesicular (varicella-like) eruptions, and erythema multiforme-like
lesions. An erythematous, polymorphic rash has also been associated with a related multisystem
inflammatory syndrome in children
page 13

14. Laboratory findings
page 14
. In a systematic review of laboratory confirmed cases of COVID-19 in
children <18 years
The complete blood count was normal in most children;
17 % had low white blood cell count and 13 % had either neutropenia or
lymphocytopenia; severe neutropenia has been described
Approximately one-third had elevated C-reactive protein
Elevated inflammatory markers and lymphocytopenia may indicate
multisystem inflammatory syndrome in children (MIS-C)
Creatinekinasewaselevatedin 15percent
Serumaminotransferaseswereelevatedin 12percent
lactate dehydrogenase (LDH) was another common laboratory
abnormality .
Kidney dysfunction may occur in severely ill children.

15. Imaging findings are variable and may be present before symptoms !
In a systematic review that included 674 children with confirmed COVID-
19 infection who underwent imaging, approximately 50 % had
abnormalities .
Among 605 children who underwent computed tomography ;
33 % had normal findings,
29 % had ground glass opacities,
27 % had nonspecific unilateral findings
23 % had bilateral findings.
page 15
Imaging findings

16. Test category
Primary clinical
use
Specimen type Performance characteristics Comments
NAATs
(including RT-
PCR)
Diagnosis of current
infection
Respiratory tract
specimens*
•High sensitivity and specificity in
ideal settings.
•Reported false-negative rate ranges
from <5 to 40%,
•Time to perform the test
ranges from 15 minutes to 8
hours...
Serology
(antibody
detection)
Diagnosis of prior
infection (or
infection of at
least 3 to 4 weeks'
duration)
Blood
•Sensitivity and specificity are highly
variable.
•Detectable antibodies generally take
several days to weeks to develop;
IgG usually develops by 14 days after
onset of symptoms.
•Cross-reactivity with other
coronaviruses has been reported.
•Time to perform the test
ranges from 15 minutes to 2
hours..
.
Antigen tests
Diagnosis of current
infection
Nasopharyngeal
or nasal swabs
•Antigen tests are generally less
sensitive than nucleic acid tests.
•Sensitivity is highest in
symptomatic individuals within 5
to 7 days of symptom onset.
•Time to perform the test is
<1 hour.
page 16

17. When consider +ve test for reinfection ?
CDC suggests that the possibility of reinfection be investigated in
patients who :
• ●Have a repeat positive NAAT ≥90 days after the initial infection,
regardless of symptoms or
• ●Have a repeat positive NAAT 45 to 89 days after the initial
infection AND have symptoms consistent with COVID-19 (with
no alternative explanation or in the setting of recent exposure)
page 17

18. page 18
Risk factor for sever
covid19
Viral factors
Genetic factors
Laboratory
Comorbidities
Socioeconomic
background and gender

19. Comorbidities the CDC classifies as established or
possible risk factors for severe COVID-19[
Established risk factors
•Cancer
•Chronic kidney disease
•Chronic obstructive pulmonary disease
• Down syndrome
•Immunocompromised state from solid organ
transplant
•Obesity (body mass index ≥30 kg/m
2
)
•Serious cardiovascular disease
•Heart failure
•Coronary artery disease
•Cardiomyopathies
•Sickle cell disease
•Type 2 diabetes mellitus
page 19
Possible risk factors
•Asthma (moderate to severe)
•Cystic fibrosis
•Hypertension
•Immunocompromised state from hematopoietic cell transplant,
HIV, use of corticosteroids or other immunosuppressing agents,
other immunodeficiencies
•Liver disease
•Neurologic conditions,
•Overweight (body mass index ≥25 but <30 kg/m
2
)
•Pulmonary fibrosis (having damaged or scarred lung tissue)
•Thalassemia (a type of blood disorder)
•Type 1 diabetes mellitus

20. Abnormality Possible threshold
Elevations in:
•D-dimer >1000 ng/mL (normal range: <500 ng/mL)
•CRP >100 mg/L (normal range: <8.0 mg/L)
•LDH >245 units/L (normal range: 110 to 210 units/L)
•Troponin
>2× the upper limit of normal (normal range for
troponin females 0 to 9 ng/L; males 0 to 14 ng/L)
•Ferritin
>500 mcg/L (normal range: females 10 to 200
mcg/L; males 30 to 300 mcg/L)
•CPK
>2× the upper limit of normal (normal range: 40 to
150 units/L)
Decrease in:
•Absolute lymphocyte count <800/microL (normal range for age ≥21 years
page 20
Laboratory features associated with severe COVID-19[1-6]

21. page 21
Viral factors — Patients with severe disease have also been reported to have higher viral RNA levels
in respiratory specimens than those with milder disease ,although some studies have found no
association between respiratory viral RNA levels and disease severity .
Detection of viral RNA in the blood has been associated with severe disease, including organ damage
(eg, lung, heart, kidney), coagulopathy, and mortality
Genetic factors — Host genetic factors are also being evaluated for associations with severe disease
As an example, identified a relationship between polymorphisms in the genes encoding the ABO
blood group and respiratory failure from COVID-19 (type A associated with a higher risk) Type O has
been associated with a lower risk of both infection and severe disease
Socioeconomic background and gender — Certain demographic features have also been associated
with more severe illness.Males have comprised a disproportionately high number of critical cases and
deaths, in multiple cohorts worldwid

22. page 22
MANAGEMENT
Features of Kawasaki disease — Patients
who meet criteria for incomplete or complete
KD should receive standard therapies for KD,
including IVIG, aspirin, and, if there are
persistent signs of inflammation or coronary
artery (CA) dilation/aneurysm, glucocorticoids
Antibiotic therapy — patients presenting with severe
multisystem involvement, particularly those with
shock, should receive prompt empiric broad-spectrum
antibiotic therapy pending culture results.
ceftriaxone plus vancomycin. Ceftaroline plus piperacil
lin-tazobactam is an alternative regimen, particularly
for children with acute kidney injury. Clindamycin is
added if there are features consistent with toxin-
mediated illness (eg, erythroderma).
Cardiac dysfunction
IVIG is often used Patients with
significant LV dysfunction are
treated with intravenous diuretics
and inotropic agents, such
as milrinone, dopamine,
and dobutamine,
Shock — most children with MIS-C
presented with vasodilatory shock that was
refractory to volume expansion. Epinephrine
or norepinephrine are the preferred vasoactive
agents for the management of fluid-refractory
shock in children. Epinephrine is preferred
when there is evidence of left ventricular
(LV) dysfunction. In children presenting with
severe LV dysfunction, the addition
of milrinone may be helpful.

23. page 23

24. Whatis"long-COVID"? Postcovidsyndrome?
• .
page 24
"Long-COVID," also referred to as post-acute COVID-19, chronic COVID-19, or post-
COVID syndrome, refers to symptoms that develop during or after acute COVID-19 illness,
continue for ≥12 weeks, and are not explained by an alternative diagnosis.
Persistent physical symptoms following acute COVID-19 are common and typically include
fatigue, dyspnea, chest pain, and cough. Headache, joint pain,
insomnia, anxiety, cognitive dysfunction, myalgias, and diarrhea have
also been reported

25. Recoveryandlong-termsequelae
• —
page 25
Persistent symptom¶ Proportion of patients
affected by symptom
Time to symptom resolutionΔ
Common physical symptoms
Fatigue 15 to 87% 3 months
Dyspnea 10 to 71% 2 to 3 months
Chest discomfort 12 to 44% 2 to 3 months
Cough 17 to 26% 2 to 3 months
Anosmia 13% 1 month
Less common physical symptoms
Joint pain, headache, sicca syndrome,
rhinitis, dysgeusia, poor appetite,
dizziness, vertigo, myalgias, insomnia,
alopecia, sweating, and diarrhea
<10% Unknown (likely weeks)
Psychologic and neurocognitive
Post-traumatic stress disorder 24%
6 weeks to 3 months
Impaired memory 18%
Poor concentration 16%
Anxiety/depression 22%

26. ShouldNSAIDsbeavoided?
observational studies have found no association between NSAID use and
worse outcomes compared with acetaminophen use or no antipyretic use.
The European MedicinesAgency (EMA),WHO, and the United States NIH COVID-19Treatment
Guidelines Panel do not recommend that NSAIDs be avoided when clinically indicated [

27. Useofnebulizedmedications safeornot?
— Inhaled medications should be administered by
metered dose inhaler, whenever possible, rather than
through a nebulizer, to avoid the risk of aerosolization
of SARS-CoV-2 through nebulization.

28. Patientwithasthmacontinues ontreatmentornot?
all regular medications necessary to maintain asthma control, including
inhaled glucocorticoids, oral glucocorticoids, and biologic agents (eg,
omalizumab, mepolizumab, and others), should be continued during the
COVID-19 pandemic

29. PatientonACEinhabitor?
ACE inhibitors and angiotensin receptor blockers — Children receiving
angiotensin-converting enzyme (ACE) inhibitors should continue treatment with
these agents if there is no other reason for discontinuation (eg, hypotension,
acute kidney injury) . This approach is supported by multiple guideline panels

30. Patient with malignancy and chemotherapy?
Although the relationship between immune compromise and severe
COVID-19 disease has not been well established in children management
of viral infections in immunocompromised hosts typically includes
reduction of baseline immunosuppression, if reduction is possible

31. Cancoronavirusdisease2019(COVID-19)bepassedfrommotherto
fetusorthroughbreastmilk?
page 31
Based on limited data, no confirmed cases of
vertical mother-to-fetus intrauterine transmission
of the virus have been reported thus far. To date,
SARS CoV-19 has not been detected in breast
milk.

32. Is the new variant likely to trigger more serious illness in children, like
MIS-C?
• After COVID-19 infection, children develop a severe inflammatory
illness), So far, B.1.1.7 does not appear more likely to trigger MIS-C, or
other serious illness in children, compared with the older variants of the virus.
• Studies in the U.Kseem to show that B.1.1.7 is more common than the older
COVID-19 variants in children and adolescents up to age 19. But the reasons
are not known.
• The good news is that even in the U.K, children infected with the B.1.1.7
variant appear to have no or very mild symptoms.
3/12/2021 32

33. WilltheCOVID-19vaccinesstillbeeffectiveagainstthisnewvariant?
• .
• The COVID-19 vaccines currently designed to prevent infection
by the virus in a variety of different ways.
• The B.1.1.7 variant hasn’t acquired enough mutations so that it
could escape coverage by the vaccines,”. “It would take a long
time, maybe years, for the virus to build up enough mutations so
that they would have an impact on the vaccines.
• the vaccines are about 95 percent effective at preventing illness
with COVID-19.
3/12/2021 33

34. How long does natural protection from a first infection last?
• several studies suggest protection generated by a previous
infection lasts for at least a few months.
• the median interval between the first infection and
reinfection about five months.
• Meanwhile, a study from Qatar suggests protection by
natural immunity of about 95% efficacy last about seven
months .
3/12/2021 34

35. Isitmorelikely thatsomeone couldcatch Covid asecond timefromadifferent
variant?
• If you didn’t have a good immune response, you could get infected again by exactly
the same virus.
• If that immune response was good, the chances of being reinfected by the same
variant will be lower, but reinfection might still occur by other variants.
• However, the situation is not black and white as this depends on the mutations and
ability of the virus to infect the cell and its interactions with the body’s antibodies
and T-cell responses generated by the immune system as a result of the previous
infection.
• Indeed, research published this week by researchers in Oxford, revealed that people
who had recovered from Covid showed T-cell activity towards new variants,
including the South African variant. But in general their antibodies were less able to
neutralise the Kent and South African variant than the original coronavirus variant.
3/12/2021 35

36. WhatareindicationforIVIG?
page 36
 MIS-C, even in the absence of KD-like features:
 ●Shock
 ●Cardiac involvement, including any of the following:
•Depressed LV function on echocardiography
•CA abnormalities (dilation or aneurysm) on echocardiography
•Arrhythmia
•Elevated brain natriuretic peptide and/or troponin
Dosing and administration :
●For KD-like features, the dosing is the same as is used for KD (ie, 2 g/kg administered
in a single infusion over 8 to 12 hours).
●For patients without KD-like features, we typically use a lower dose (ie, 1 g/kg over 8 to
12 hours). However, some centers use a dose of 2 g/kg in this setting.
●For patients with significant LV dysfunction, will not tolerate the volume load of the full
dose in a single infusion, it can be given in divided doses over two to three days.

37. Steriod ?
page 37
Whom to treat – ?
 •Severe or refractory shock.
 •KD-like features (ie, meeting criteria for complete or incomplete KD plus a risk factor for
IVIG resistance (eg, CA enlargement [Z-score ≥2.5], age ≤12 months)
 •Persistent fevers and rising inflammatory markers (eg, C-reactive protein, D-dimer,
ferritin) despite treatment with IVIG. These findings may suggest macrophage activation
syndrome (MAS) or cytokine release syndrome (CRS; also called cytokine storm), which
may not to respond to IVIG therapy.
●Timing – Glucocorticoid therapy may be given concomitantly with IVIG if
severe or life-threatening illness is present. It also may be given as a second-line
treatment in patients who do not respond to IVIG.
●Dosing – Glucocorticoid therapy is initially given intravenously (IV) with methylprednisolone at a
dose of 2-30 mg/kg/day in two divided doses . Once improved clinically, this can be transitioned to
an equivalent oral dose of prednisolone or prednisone by the time of discharge and then tapered off
over three to four weeks.

38. shorter.Low-doseglucocorticoidregimens
page 38
the duration of therapy is up to 10 days or until discharge, whichever is shorter. Low-
dose glucocorticoid regimens include one of the following :
●Dexamethasone 0.15 mg/kg orally, IV, or nasogastrically (NG) once daily (maximum
dose 6 mg)
●Prednisolone 1 mg/kg orally or NG once daily (maximum dose 40 mg)
●Methylprednisolone 0.8 mg/kg IV once daily (maximum dose 32 mg)
Hydrocortisone
•For neonates (<1 month of age): 0.5 mg/kg IV every 12 hours for 7 days followed by
0.5 mg/kg IV once daily for 3 days
•For children ≥1 month: 1.3 mg/kg IV every 8 hours (maximum dose 50 mg; maximum
total daily dose 150 mg)

39. Antithrombotictherapy
page 39
— at risk of experiencing thrombotic complications.
For example, patients with severe LV dysfunction are at risk
for apical LV thrombus and those with KD who have large or
giant CA aneurysms are at risk for myocardial infarction

40. Contoso
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41. Summary
Summary tagline or
sub-headline
page 41
Currently, remdesivir is the only drug approved by the Food and Drug Administration
(FDA) for the treatment of COVID-19 in hospitalized patients .. Remdesivir is also
available for younger children (and those weighing 3.5 kg)

42. page 42
Hydroxychloroquine and
chloroquine
recommend not using hydroxychloroquine or
chloroquine for the treatment of COVID-19 in
children, except in the context of a clinical trial.
The efficacy of hydroxychloroquine in the
treatment of COVID-19 is uncertain .
Hydroxychloroquine is not licensed for this
indication,.
It is ideally used only in hospitalized patients
in the context of a clinical trial

43. Contoso
Pharmaceuticals
Copyrights apply
,. Last Updated: February 11, 2021
Summary Recommendations
• There are insufficient data for the COVID-19 Treatment
Guidelines Panel to recommend either for or against the use of
vitamin C,D, Zinc for the treatment of COVID-19.
• The Panel recommends against using zinc supplementation
above the recommended dietary allowance for the prevention of
COVID-19

44. Thank you
Thank you
Thank you
Thank you