COVID 19- Priorities in Pediatric Practice

8/24/2020 Arati Mishra Ingalageri 1

COVID – 19 : PRIORITIES FOR PEDIATRIC
PRACTICE
MRS.Arati Mishra Ingalageri
M.Sc. Nursing (Pediatrics)
VICE PRINCIPAL
SET INSTITUTE OF NURSING- Junagadh

INTRODUCTION
• Coronavirus disease 2019 (COVID-19) is an acute infectious respiratory disease
caused by a newly discovered coronavirus (SARS-CoV-2).
• Previously SARS(Severe Acute Respiratory Syndrome-2002-2004), MERS
(Middle East Respiratory Syndrome-2012-2014) Epidemic was happened by Same
virus Family.
• COVID-19 is a zoonotic, enveloped, single-stranded ribonucleic acid (RNA) virus
that can quickly mutate and recombine, creating novel virus strains that spread
from animals to human and resulted in Pandemic situation as human don’t have
immunity for this virus.
• Coronaviruses are known for causing severe respiratory distress and respiratory
failure along with coagulopathies, multi-system organ failure, and death.

STATISTICS AND DATA
• Children and Adolescents currently account for about 8% of confirmed
COVID 19 Cases in the world, which shows a smaller percentage of total
COVID-19 cases occurring in children
• Up to 13th August 2020,As per Centers for Disease Control and Prevention
7.6 % of 37,04,108 confirmed cases reported in children < 18 years.
1.6% of cases were in children aged 0-4 years
 6% of cases were in children aged 5-17 years
• 40% increase in cases of COVID-19 is reported in children in July 2020.

RISK FACTORS
• Exposure to household members with confirmed COVID 19
• Immuno compromising conditions such as ongoing treatment for cancer
• Congenital heart defects
• Chronic lung disease
• Moderate-to-severe asthma
• Severe obesity
• Diabetes
• Chronic kidney and liver disease
• Infants < 1 year old may be at increased
risk of severe or critical disease compared
to older children.8/24/2020 Arati Mishra Ingalageri 6

TRANSMISSION
• Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) is transmitted
person-to-person.
• Primarily through close contact (within 6 feet) via respiratory droplets
produced when an infected person coughs or sneezes.
• Children carry the COVID-19 virus in the upper respiratory tract, making it
easier to spread in childcare centers, schools, and homes; where pediatric
respiratory hygiene is inconsistent and problematic.

Continue….
• Contact with fomites may be possible, but it is not thought to be the primary
route of transmission
• Viability of SARS-CoV-2 suggests aerosol and fomite transmission,
6.8 hours on plastic
5.6 hours on stainless steel
3.5 hours on cardboard
1.1 hours in aerosol
0.8 hours in copper
• SARS-CoV-2 may be spread by people who are not showing symptoms

CLINICAL MANIFESTATION
• It appears children present with similar symptoms described in adults
with active COVID-19 infection although most are either asymptomatic
or mildly symptomatic.
• Among all COVID 19 Confirmed Cases,
 80% mild
14% Severe
5% critical and
Fatality is 1-3%.
• Incubation Period of COVID 19 Virus is 2-14days.

• COVID-19 symptoms including,
• Fever
• Cough
• Shortness of Breath or difficulty in Breathing
• Chills, shivering
• Muscle aches
• Headache
• Sore throat
• Loss of taste and/or smell
• Congestion or running nose
• Nausea or Vomiting
• Diarrhea
• Poor Appetite

Continue…
• Multisystem Inflammatory Syndrome in Children (MIS-C) is a new syndrome
being reported in small number of children during the COVID-19 pandemic
syndrome.
• It has features similar to other pediatric inflammatory conditions including
Kawasaki syndrome.(Bulbar non purulent conjunctivitis, cervical
lymphadenopathy, Strawberry tongue, Skin desquamation, Coronary artery
dilatation)

Continue…..
• COVID-toes.

INVESTIGATIONS
Supportive Investigation
 Serological Investigation Includes,
• WBC normal or decreased
• Decreased neutrophils
• Thrombocytopenia
• CRP and procalcitonin Normal
• In Severe Cases:
 Elevated liver Enzymes,
Abnormal coagulation Studies
Elevated D-dimer

Continue…..
 Radiological Investigation Includes,
• Bi-lateral, multiple patchy nodular
ground-glass opacities
• Infiltrating shadows in the middle/outer
zone of the lung or under the pleura
• Findings are often non-specific
Children have milder presentations than
adults Chest abnormalities may persist
for several months.

 Confirmatory Investigation
• Diagnosis confirmed with detection of SARS-CoV-2
RNA by reverse transcription polymerase chain
reaction (RT-PCR) in nasopharynx, oropharynx, or
nasal swab samples.
• Various commercially available kits are approved by
ICMR for use in India.

TREATMENT
• It mainly consists of supportive care with provision of sufficient fluid and
calorie intake along with oxygen supplementation and airway support.
• Use of Remdesivir (Antiviral) for treatment of suspected or confirmed
COVID-19 in children.
• Use of Favipirivir For Treatment of moderate to sever cases.
• Use of Tociluzumab (IL6 Antagonist) for Treatment of sever cases.
• Supportive care may help to relieve symptoms and should include support of
vital organ functions in severe cases
• Vitamin D,Vitamin C, and Zinc Supplementation may play a role in reducing
the risk of COVID-19 infections.

INDICATIONS FOR HOSPITAL
ADMISSION
• At present, the official guidelines recommend admission for
all confirmed cases. Particularly, patients classified as
“Severe Pneumonia” and “Critically ill” should be admitted to
hospital for further care. The following criteria may
particularly be considered for admission:
1. Respiratory distress
2. SpO2 < 92% on room air
3. Shock/ poor peripheral perfusion
4. Poor oral intake, especially in infants and young children
5. Lethargic, especially in infants and young children
6. Seizures/ encephalopathy8/24/2020 Arati Mishra Ingalageri 19

GENERAL MEASURES FOR
HOSPITALISED CHILD
• Oxygen supplementation to maintain SpO2 > 92%.
• Fluid management to prevent dehydration and overhydration.
• Symptomatic treatment (Paracetamol for fever).
• Avoid ibuprofen and other NSAIDs.
• Use of antimicrobials (e.g., Ceftriaxone) in case of suspected sepsis and septic
shock and use of antiviral (Oseltamivir) if influenza is suspected.
• Systemic corticosteroids if needed.
• Avoid Nebulization to prevent risk of aerosolization
• Use of inhaler and spacer is preferred for administration of inhaled medication.
• Close monitoring for Danger signs.
• Care of child with Ventilator.8/24/2020 Arati Mishra Ingalageri 20

MANAGEMENT
Children with cough/cold/fever of less
than 10 day duration
• No respiratory
Difficulty
• Feeding well
• SpO2 >92%
• Respiratory difficulty,
• SpO2 <92%,
• Not feeding well or
• Lethargic,
• Seizures
• Hospitalization if not
feasible- Home treatment
• Parental Education about
isolation
• Report to health care
facility if worsening of
Symptoms
• Home treatment
• No investigation
• Parental Education
about isolation and
• Report to health care
facility if worsening of
symptoms
Contact
No Contact
Continue…8/24/2020 Arati Mishra Ingalageri 21

• Initiate appropriate management
• Admit in designated ward till COVID report is available
Ward/ ICU:
COVID Sampling
Bedside Chest X-ray,
Lab tests
COVID test
POSITIVE
COVID test
NEGATIVE
Transfer to Designated area-ward/ ICU.• Transfer to ward/PICU and
• Manage as bronchiolitis/ CAP

Children with COVID 19 RT-PCR Positive
 Mild illness
• sore throat
• Rhinorrhea
• Cough
• No fast Breathing
 Pneumonia
• Fast breathing
• No signs of sever
pneumonia
 Severe pneumonia
• Cyanosis(SpO2 < 90%)
• Increased respiratory
Efforts (Grunting, severe
retraction)
• Lethargy somnolence,
• seizure
 Critically ill
• Hospitalization if not feasible
Home isolation
• Supportive care
• Rest
• Adequate Hydration and
feeding
• PCM 10-15mg/kg for fever
• Explain Danger Signs.
• Hospitalization if not feasible Home
isolation
• Monitor for progress
• Feeds / fluids: avoid dehydration
and overhydration
• Paracetamol
• oral antibiotics(amoxiclav)
• Explain Danger Signs.8/24/2020 Arati Mishra Ingalageri 23

 Severe
pneumonia
 Critically ill
• Hospitalization in Isolation
• Hydroxy chloroquine Or Lopinavir/ritonavir
• Oxygen therapy: nasal prong, face mask
• Avoid nebulization
• Use Inhaler and spacer.
• Avoid HFNC(High Flow Nasal Cannula)
and NIV(Non Invasive Ventilation ) for
Prevention of aerosolization.
• Hospitalization in Isolation
Preferably Negative Pressure
room
• Hydroxy chloroquine Or
Lopinavir/ritonavir
• Monitor for secondary Bacterial
Infection Consider Antibiotics
• Organ support – renal
replacement.(if needed)
 Septic Shock/Myocarditis
• Crystalloid bolus 10-20
ml/kg over 30-60 min, fast
if hypotensive
• Early inotrope support
• (Dopamine,Dobutamine)
• Monitor for fluid overload
 ARDS
• Mechanical
ventilation:
• Low tidal volume
(6 ml/kg)
• High PEEP
• Cuffed ET tube
• Fluid Restriction
• Try prone Ventilation
• HFOV may be
considered
• ECMO if above fail8/24/2020 Arati Mishra Ingalageri 24

DISCHARGE CRITERIA
• For mild cases Patient can be discharged after 10 days of
symptom onset and no fever for 3 days and advised to isolate
at home for further 7 days for mild cases.
• For moderate cases admitted to dedicated COVID health
centers, if fever resolve with in 3 days and maintain saturation
above 95% for next 4 days such patient will be discharge
after10 days of symptom onset and advise for 7 days home
isolation.
• For Severe Cases Clinical recovery and tested negative by RT-
PCR .

Management of Neonates born to
Mothers with Suspected or
Confirmed COVID-19
• Prevention of transmission
• Contact between mother and neonate
• Breastfeeding
• Management of neonate requiring intensive care
• Visiting neonate admitted to NICU
• Infection control

Prevention
• Vaccine is best strategy for prevention of any infectious disease.
• For COVID 19 vaccine is under Trial Phase.
• Till that general preventive measures like
 Cough etiquette
Social Distancing

Continue…
Hand Hygiene.
Healthy Diet
Yoga, Exercise
Luke warm water gargles.

COVID 19 Pediatric v/s Adult
• Recurrent viral infections going on in children up to 5 year of
age so that there immune system is active to fight against new
agent.
• Vaccination will be going on so immune system get stimulated
,All primary vaccination should be given as per schedule
specially prevenar and influenza (First time 2 doses and yearly
once there after).
• Cytokine storm will be less in children as immune system is
developing.
• Cytokine storm play a vital role in severe COVID-19 because
it is associated with ARDS and respiratory failure in patients
with COVID-198/24/2020 Arati Mishra Ingalageri 31

Advice for Parents/ Adults who have COVID-19 and
are Staying at Home with a Child
• The affected person should stay in a separate room.
• The affected person should use a 3-ply surgical mask.
• Household members should stay in a different room and be separated from the person as
much as possible.
• Only an assigned family member should be tasked with taking care of the person and should
help with groceries, prescriptions and other personal needs.
• Avoid shaking the soiled linen or direct contact with skin.
• Use disposable gloves when cleaning the surfaces or handling soiled linen.
• Wash hands after removing gloves and before and after eating, drinking & using the
washroom with soap &water (at least 20 s) or with alcohol-based hand sanitizer (at least 30 s).
• Toys that the child plays with should be washed frequently, wherever possible.
• Currently, no prophylaxis is recommended for children.

Management of Psychological
Issues of Children.
• Provide assurance when ever needed
• Manage child’s Anxiety
• Engage them in indoor activity
• Keep them in contact with their Friends
• Give them clear information
• Make a routine of learning at home

Implications For Pediatric Nurse
Practitioners For Routine Vaccination
• It is important to continue routine vaccination against vaccine preventable disease,
other wise there will be surge of these cases which may over burden health facility.
• The National Association of Pediatric Nurse Practitioner recommends innovative
solutions to provide safe opportunities to keep vaccination schedules on time including:
1) Separating well and sick visit hours,
2) Staggering appointment times,
3) Closing waiting rooms,
4) Reminding families about upcoming vaccines,
5) Using every patient encounter as an opportunity to administer vaccines
6) Administering as many simultaneous vaccines as possible.

Strategies for Pediatric OPD and
Emergency Room
• Never allow more then 5 to 10 people at a time.
• Discourage Healthy patient to attend OPD.
• Encourage Telemedicine.
• Separate Waiting Area for patient with flu like symptoms and others.
• Limit number of patient who accompany the patient.
• Face mask and Hand wash or Hand Sanitization is compulsory for all
before entering OPD.

Continue…
• Encourage cashless transaction.
• Focus on cleaning OPD (Use 1% Hypochlorite solution) every 4 hrs.
• Stethoscope and Thermometer Should be clean between Patient.
• All doctors, nurses in OPD and front desk receptionist must wear face mask.
• Manage OPD According to time slot given by appointment to prevent over
crowding.
• Maintain well ventilated waiting area with social distancing.

GUIDANCE FOR SCHOOL RE-ENTRY
• The AAP (American Association of Pediatrics)strongly advocates that all policy
consideration for coming school year should start with goal of having students
physically present in school with all precautions.
• Key Principles for School Re entry are,
 To open schools safely It is vitally important that community take all necessary
measures to limit the spread of COVID 19.
 Schools must take a multi pronged layered approach to protect students teachers
and staff.
 School authorities must be in close communication and co ordinate with state
and local health authority.8/24/2020 Arati Mishra Ingalageri 37

Continue…
• School re entry should be practical , feasible and appropriate for child
development and address teacher and staff safety.
• Pediatricians, families and schools should partner together to collaborate
identify and develop Accommodation when needed for any child with
unique medical needs.
• School policies should be guided by Supporting over all health and well
being of children, their families and their communities but should also look
to create safe working environment for educators and school staff.

Key Challenges Faced by Nursing
Professionals During COVID-19
• Providing Support to Reduce Gaps in Critical Knowledge
• Preventing Inadequacies in the Healthcare System
• Policies and Strategies to Prevent Staffing Shortages
• Psychological and Social Support for Patients and Healthcare Professionals
• Research to Enhance Knowledge on COVID-19 Prevention and Management

THANK YOU…….

COVID 19- Priorities in Pediatric Practice

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