This document provides guidance on managing COVID-19 in neonates and pediatric patients. It covers case definitions, clinical presentation, assessment of severity, management approaches for mild, moderate and severe illness, treatment considerations, infection control measures, vaccination guidance and more. The key recommendations are to manage mild cases at home, admit moderate to severe cases to a dedicated facility, provide oxygen support and IV fluids as needed, consider corticosteroids for severe illness, and follow infection control protocols. Vaccine trials are underway but immunizing family members is currently the best indirect protection for children.

1. 3rd
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Wave COVID TOT –(9)
Pediatrics

2. Beneficiaries - Participants
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• Nursing Staff
• Paramedical Staff

3. Learning Objectives
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• Management of covid-19 Infection in newborn and
children
• Clinical features and assessment of severity
• Treatment according to severity: Mild, Moderate,
Severe
• Prevention and Vaccines in children

4. Covid in Neonatal Age
Learning Objectives
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• Challenges in Neonatal Care
• Clinical importance of Covid-19 in neonates
• Delivery Room care
• Rooming-in, Breastmilk feeding and KMC
• Immunization
• Communication and Counseling
• Protection from Covid-19

5. Case Definition -Neonate
● Suspected COVID-19 Neonate
- Born to mother with a history of COVID19 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
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6. Testing for Neonate
• Ideally as soon as possible but preferably within
24-48 hours of delivery.
• If the first report is negative then a repeat test
needs to be done between 5-14 days.
• Nasopharyngeal and Oropharyngeal swabs need
to be collected and if intubated, then tracheal
secretions need to be collected for testing.
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7. Delivery Room Care of Newborn - born to
Covid Suspect/Positive mother
• NRP remains the same : Thermal
protection, blended oxygen, T-
piece resuscitator, CPAP
• Delayed Cord Clamping
• Skin To Skin contact
• Early Initiation of Breast Feeding
Precautions
• Resuscitation corner 2m away ;
N95 mask, face shield, gown and
gloves; Triple layered surgical
mask for mother
• Plexiglas head box for
suction/intubation
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8. Neonatal Manifestations
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• History of exposure to a contact or infection in mother
are clues
• Asymptomatic presentation in a major proportion
• Symptomatic – three types of presentation
• Milder illness (A), Moderate (B) & Severe Disease (C)
- The immature immune system,
- Passive transfer of maternal IgG antibodies, and
- LowerACE-2 expression

9. Rooming-in , Breast feeding
&
Kangaroo mother care (KMC)
• Room-in baby with mother if both are
medically stable
•Support direct breastfeeding or expressed breast
milk feeding
• Provide KMC with contact precautions
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10. Support
Breast feeding
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11. Promote KMC
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12. Immunization &
Family Participation
• Follow routine immunization policy
•One ‘healthy’ family member following contact and
droplet precautions, should be allowed to stay with
mother to assist in baby care activities.
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13. Communication & Counseling
Follow-up
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• Families should be informed and explained the restrictions,
diagnostic and treatment plans and be given regular periodic
updates.
• Use video/phone calls to compensate for the visitor
restrictions
• Re-assess as per usual follow-up schedule
• Provide “Explicit information” about whom to contact and
visit in case of symptoms

14. Extra Precautions During Pandemic
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• Discharge mother and baby to home at the earliest once they are
medically stable
• At home, extra precautions---baby should not be handled by
multiple people
• Correct masking and hand hygiene by mother and all family
members
• Good hygiene, clean environment and natural ventilation/light for
mother-baby
• Standard Care of mother and baby at home after discharge

15. Case Definition of Paediatric Covid
 Probable Case:
• Asuspect case for whom RT – PCR testing for Covid – 19
virus is inconclusive.
OR
• Asuspect case for whom RT – PCR test could not be performed
for any reason.
 Confirmed Case:
Aperson/ child with laboratory confirmation of Covid – 19
infection irrespective of clinical signs and symptoms.
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16. CLINICAL FEATURES
• Majority -asymptomatic or mildly symptomatic.
Common symptoms
• Fever
• Cough, breathlessness/ shortness of breath,
• Fatigue, myalgia
• Rhinorrhea, sore throat
• Loss of smell, loss of taste
• Diarrhoea
• Few children may present with gastrointestinal symptoms
and atypical symptoms also.
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17. IF BROUGHT BY AMBULANCE /
EMERGENCY : Must do ETAT
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• CHECK FOR Emergency TreatmentAnd Triage
HR:………../MIN RR:
BP: …………….(not mandatory)
OR
• T: ……….
………../MIN
• Spo2: ………..
• Chest indrawing –present
• Severe respiratory Distress(RR>70/min) OR
• Low SPO2 as per latest guidelines OR
• Gasping respiration/ No breathing/central cyanosis OR
• CRT: <3sec OR
• Cold extremities: Yes OR
• Convulsive (On Arrival) OR
• Comatose/ Unconsciousness/Decrease activity OR
• SIGN OF SEVERE DEDHYRATION
(lethargy, sunken eyes, very slow skin pinch)

18. DANGER SIGNS /
RED FLAG SIGNS
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19. DANGER SIGNS /
RED FLAG SIGNS
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20. DANGER SIGNS /
RED FLAG SIGNS
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21. Transport of Sick
Newborn / Pediatrics Patient
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22. Assessment of Severity Based on Clinical
Features & Management
Mild illness
Sore throat,
Rinorrhea,
cough.
No fast breathing
Moderate illness
Pneumonia
Fast breathing (age based
:
≥60/min for <2months,
≥ 50/min for 2-12 months,
≥ 40/min for 1-5 years,
≥ 30/min for >5years.
No signs of severe
pneumonia/illness
Severe illness*
Severe pneumonia
ARDS, Sepsis, Septic Shock,
MODS
Pneumonia with any of these: Cyanosis
SpO2 < 90%
Increased respiratory efforts
(grunting, severe retraction)
Lethargy, somnolence, seizure
•Includes Critical illness defined by WHO
Clinical
Classification
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23. MANAGEMENT OF MILD ILLNESS
• Symptomatic treatment
• For Fever: Paracetamol 10-15 mg/kg/dose; may repeat every 4-6
hours
• For Cough: Throat soothing agents like warm saline gargles- in
older children and adolescents
• Fluids & feeds: Ensure oral fluids to maintain hydration, and
nutritious diet
• Antibiotics: Not indicated
• NO ROLE of Hydroxychloroquine, Favipiravir, Ivermectin,
lopinavir/ritonavir, Remdesivir, Umifenovir, Immunomodulators
including Tocilizumab, Interferon B 1 a, Convalescent plasma
infusion or dexamethasone.
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24. Care at Home
Monitoring at Home
• Explain parents/ care taker to maintain a monitoring chart
• Counting of respiratory rates 2-3 times a day when child is not
crying, looking for chest indrawing,
• bluish discoloration of body, cold extremities,
• urine output, fluid intake, activity level, esp. for young
children.
• oxygen saturation monitoring (hand held pulse oximeter) if
feasible,
Regular communication to doctor or health care worker.
Whom to contact in case of emergency.
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25. Moderate Disease:
• Rapid respiration rate for the age
- less than 2 months: respiratory rate >60/ min,
- 2 to 12 months: respiratory rate >50/min,
- 1 to 5 years: respiratory rate >40/min,
- more than 5 years: respiratory rate >30/min.
- And oxygen saturations <94% but above 90%.
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26. MANAGEMENT OF MODERATE
ILLNESS
• Admit in Dedicated Covid Health Centre (DCHC) or
District hospital or Medical College hospitals
• Investigations :As per requirement, not required in all.
• Hematology & biochemistry laboratory testing
• Electrocardiogram and
• Chest imaging
• Oxygen supplementation to maintain SpO2 > 94%
• Inhaled bronchodilators if wheezing : MDI with spacer is
preferred over Nebulization to reduceAerosolization
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27. NASAL PRONGS
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28. OXYGEN CONCENTRATOR
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29. MANAGEMENT OF MODERATE
ILLNESS
• Maintain fluid and electrolyte balance.
• Empiric antibiotic therapy if clinical suspicion of a
bacterial infection
• Monitor for clinical progress.
• Encourage oral feeds (breast feeds in infants)
• if oral intake is poor, intravenous fluid therapy should
be initiated.
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30. Severe Disease
• SpO2 level less than 90%
• Severe pneumonia, or pneumonia with cyanosis
• Clinically present with grunting, severe retraction of
chest, lethargy, somnolence, seizure
• Acute Respiratory Distress Syndrome
• Septic Shock
• Multi-organ dysfunction syndrome (MODS)
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31. MANAGEMENT OF SEVERE ILLNESS
• Intravenous fluid therapy
• Corticosteroids
Dexamethasone 0.15 mg/kg per dose (max 6 mg) twice a day -
preferred.
Equivalent dose of Methylprednisolone may be used for 5 to 14 days
depending on continuous clinical assessment.
• Anti-viral agents: Remdesivir NOT RECOMMENDED
• No Role of Hydroxychloroquine, Favipiravir, Ivermectin,
lopinavir/ritonavir, Umifenovir
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32. Treatment…Continue
 Give supplemental oxygen therapy to target SpO2 >94% during
resuscitation and >90% for stable and recovering children
 Nasal prongs are preferred - better tolerated
 Oxygen hood cover -decrease the risk of aerosolization and
droplet spread
 If the child is on oxygen through prongs and SpO2 less than 90%
with minimal respiratory distress, options include
 Face mask at flow > 5 LPM (FiO2 40 - 60%)
 Oxygen hood at flow > 5 LPM (FiO2 30-90%)
 Non-rebreathing mask at flow 10-15 LPM (FiO2 80-90%)
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33. MANAGEMENT OF CRITICAL ILLNESS
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• In Covid -19 ICUs/ PICUs with a dedicated & trained team
who can follow Local/Universal IPC policy
• RSI protocols for an Intubation
• Timely Weaning-No undue delay
• Maintenance of Enteral or Parenteral Nutrition
• Prone position ventilation
• Care of IV lines (Central & Peripherals ) and Catheters
• Inotropes as per the age and weight

34. Dedicated...
Monitoring
...Monitoring.....Monitoring...
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• Judicious use of Sedation &Analgesia
• Proper suction : use close suction system
• Antibiotics *(sos) if needed
• Use ofAirbed
• DVT & Thromboembolism Prophylaxis – Heparin
(LMWH)
• Chest Physiotherapy
• Supportive Immunoboosters : Vit A, Vit D, Vit B1, Vit C ,
Zinc

35. High Flow Nasal Cannula (HFNC)
• Indications- not maintaining saturation > 90% on NRBM
• Start flow 0.5 lit/kg/ min and increase upto 2 lit/kg/min
• If no response (SpO2/FiO2 < 220 or FiO2 > 0,4 for SpO2 > 92% ,
other respiratory support should be considered.
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36. Indication of Invasive ventilation
• Persistent or worsening of respiratory
distress
• Spo2 88-90% on HHFNC/NIV with
FiO2 0.6
• Refractory Shock
• MODS
• Severe hypercapnea
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37. Protection from
Covid-19
• Standard Infection Control Measures
• Contact precautions
• Universal masking as per GoI/ICMR guideline
• Physical distancing ( inside and outside the unit e.g.
duty/eating room )
• Hand Hygiene
• Use of gowns /hospital dress
• Use of appropriate gloves for procedures
• Environmental cleaning—Disinfection of Hi-touch surfaces
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38. VACCINES IN CHILDREN-
WAY FORWARD
• Trials are underway for vaccine efficacy and safety
• However, fully vaccinated adults in the family and COVID appropriate
behaviour –indirect protection to children by immunising all eligible
adult members of the family
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39. TAKE HOME MESSAGES
• Children can be managed at home, if asymptomatic/ mildly
symptomatic
• Moderate and severe illness are managed in in-patient
facility
• Rational use of medications is required
• Trials of vaccines in children underway; guidance likely to
be based on documentation of safety and efficacy
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40. REFERENCES
• https://mohfw.gov.in COVID 19 management (1 month-19years), statement by IAP June 2021
• www.cdc.gov1.WeVent: Grupo Internacional de Ventilación Mecánica. Respiratory
Management Protocol of Patients with Sars-CoV-2 (COVID-19). (2020) [ Links ]
• https://espnic-online.org/News/Latest-News/Practice-recommendations-for-managing-
children-with-proven-or-suspected-COVID-19
• https://www.nature.com/articles/s41390-020-1053-9
• https://pubmed.ncbi.nlm.nih.gov/32634818/
• Facility Based Paediatric care during Covid-19 MPVer-2
• https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03021-2
• https://www.nature.com/articles/s41390-020-1053-9
• Critical Care for COVID-19Affected Patients: Position Statement of the Indian Society of
Critical Care Medicine
• Operationalization of COVID care services for children and adolescents, GOI, June 2021
• Directorate General of Health Services, Ministry of Health and Family Welfare, Government
of India Comprehensive Guidelines for Management of COVID-19 in CHILDREN (below 18
years), June 2021
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41. THANK YOU
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