Amidst the concerns that children will be the target in the third wave of COVID-19, they have come up with certain guidelines to manage COVID in children. Learn more about the management of COVID in children.
Till date, children have been relatively spared of this severe disease and poor outcomes. The proportion of children among the confirmed cases is lower than expected. However, the health experts are expecting the third wave with a disproportionately high burden among the pediatric population. The reopening of schools and colleges may contribute to an increase in infections in children. Henceforth there arises a need to prepare for any sudden future surge of COVID cases among the pediatric age group. This article will throw some light on the guidelines for the management of COVID-19 in children.
Children have less severe disease than adults. In most cases, the infection is either asymptomatic or mildly symptomatic. It is usually not common to have moderate to severe COVID in healthy children. Children with co-morbid conditions have more severe manifestations and poorer outcomes. The children are as susceptible as adults to the infection, but a large majority remain asymptomatic. Even among the symptomatic, the vast majority of children have a mild disease only.
The data indicated that a maximum of 2-3% of children required hospitalization in the first and second wave. It is expected for a surge in COVID cases, so we need to be prepared for a higher number. To meet the surge of cases, bed facilities are required. It will be desirable to have additional capacity at the hospital level to ensure adequate projections and preparedness as it is important because the incidence of COVID is likely to be variable in different areas, and also the peak in the number of cases will also be at different time points. And also, the focus has to be at all levels and not just on ICU beds.
Considering 40% will be managed by the private sector, the remaining 60% will be dependent on the public health facilities. According to the norms given by the Indian Public Health Standards, approximately 10% of beds at a district level should be earmarked for sick children.
The symptomatic children show the following common symptoms:
They may also have other symptoms like:
Gastrointestinal symptoms like diarrhea and vomiting.
The severity of the symptomatic pediatric COVID illness ranges between
1) Children with mild COVID-19 can be managed with home isolation under the direct care of the parents.
2) Parents should be explained about the alarming signs of the progression of the disease, such as
Not accepting any feeds.
Fever without any improvement for more than five days or high-grade fever for more than three days.
3) Community health workers from ASHA or MPW should visit their home at least once daily to provide the necessary medications and for continuous monitoring of the vital signs.
4) If any worsening of symptoms is noticed, then the community health worker should contact the designated physician.
5) Community health workers should contact the patient transfer ambulance for transferring the patients to the nearby dedicated COVID-19 hospital (DCH) in case the symptoms worsen, indicating for admission.
5) The overall services should be monitored by the medical officer.
An information education campaign includes messages about the pediatric COVID. The orphanages, boarding schools, and hostels would need special attention as these can be potential hotspots. The suggested components of the information education campaign include:
1) Reassurance about the disease in children.
2) Symptoms and signs of COVID-19.
3) Need for early testing for COVID-19 in case of symptoms.
4) Principles of home isolation.
5) Avoidance of self-medication for COVID-19.
6) Whom to contact in case of emergency.
7) Not to neglect the routine immunization of the child.
8) Following all the COVID-19 guidelines like wearing a mask, washing hands regularly, social distancing, and wearing masks are recommended for those who are above the age of 5 years.
9) The community-level intervention, which includes posters, pamphlets
should be in the local language.
10) Pulse oximeters can be loaned to a family with the support of community platforms, and later it can be used for another family once the previous family recovers from the disease.
11) Once COVID vaccines are approved for the children, then the community level programs should focus on appropriate communication in order to facilitate wide coverage.
According to the guidelines, the infrastructure was augmented for managing the COVID cases, which are largely catering to adult cases due to the small incidence of pediatric cases. The infrastructure developed should be augmented for managing pediatric COVID cases in the future. This infrastructure would need additional resources to manage the increased number of child patients who often would need one accompanying family member. Children’s wards should preferably be separate from the adult wards for their mental comfort. To keep patients suspected to have COVID-19 while awaiting reports, a separate holding area is required.
These facilities should have provision for the stay of a parent or a caregiver or any family member with the child. This could be a family member who also has mild COVID or if asymptomatic, or who has previously recovered from COVID. In case the caregiver is COVID negative, he or she still can stay with the child after due counseling, appropriate consent, and providing them with an appropriate PPE kit.
MIS-C is a multisystem inflammatory syndrome in children, which is a severe post-COVID inflammatory disorder in children that is frequently associated with complications such as cardiac dysfunction, coronary aneurysms, thrombosis, and multi-organ dysfunction.
MIS-C should be suspected in children with fever for more than three days with clinical manifestations like rash, bilateral non-purulent conjunctivitis, diarrhea, vomiting or abdominal bleeding, abdominal pain, respiratory distress, or shock, especially if the child had contacted with COVID-19 patient in the past 1-2 months or had acute COVID infection.
Usually, the outcomes of COVID in pediatric patients are good. Deaths may occur occasionally. Dead body disposal for children dying due to COVID should be streamlined; the principles are the same as those for adults. Availability of pediatric size bags should be ensured. Cremation services should be equipped and sensitized to handle the bodies of the children.
Children who have suffered from the severe COVID-19 case may need enhanced care on follow-up. As there are many post-discharge complications like infectious pneumonia, invasive fungal infections like mucormycosis, thromboembolism, progressive fibrosis, and hypoxemia. So the following are recommended:
1) A pulse oximeter should be given at the time of discharge, along with the knowledge about how it should be monitored
2) Advice about the warning signs like the development of fever, persistent fall in the oxygen saturation, increased cough or breathlessness, chest pain, headache, jaw pain, tooth pain, or nasal blockage should be given.
3) Provision for home oxygen therapy in those who need it and emergency contact number in case of exhaustion of oxygen supply or malfunction of the concentrator.
4) Emergency contact numbers in case of any warning signs should be given.
5) Influenza and pneumococcal vaccination may be considered.
About 10% of the neonates who are born to COVID-19 positive mothers may be RT-PCR positive for SARS-CoV-2 during the birth hospitalization. The majority of the neonates remain asymptomatic. Occasionally moderate to severe infections with oxygen requirements can occur. A significant proportion of the neonates may, however, require special or intensive care due to prematurity and perinatal complications.
Breastfeeding, rooming-in, and kangaroo mother care should be encouraged in all cases. So the pediatric facility should have the equipment and surgical consumables suitable for neonates, including parents. Routine immunization should be done for stable neonates.
During the second wave of COVID-19, many neonates were affected with moderate to severe COVID-19 pneumonia and gastrointestinal symptoms. These neonates acquired the infection from their family members. Occasionally cases of MIS-related to COVID antibodies transmitted from the mother have also been seen. The pediatric ICU should have suitable equipment and surgical items for caring for the neonates, such as servo-controlled open care systems, air-oxygen blending systems, CPAP, ventilators capable of supporting preterms, and appropriate sized nasal interfaces and endotracheal tubes.
Since COVID-19 is highly infectious, every hospital handling COVID patients is expected to put robust infection prevention and control protocols in place.
1) Ensuring availability of water, liquid soap, and paper to dry hands and dispensers at all patient care points.
2) Availability of alcohol-based hand rub at every possible point of use.
3) Adherence to infection prevention protocols which includes cleaning, segregation, and transport.
4) Facilitate access to PPE by all categories of staff and ensuring its usage on a 24*7 basis.
5) Ventilation and air-exchanges in patient care and visitors area.
6) Collection of segregated waste from COVID patients and its labeling throughout the chain of its movements till disposal.
7) Appropriate Bio-safety measures should be followed in the laboratories as per the guidelines.
It is expected for an intermittent surge in the number of cases in the third wave, so a combined effort from the private and public sectors is needed to handle any rise in the future. So being prepared beforehand will help better in handling the surge in cases. Once COVID vaccines are approved for the children, then the community level programs should focus on appropriate communication to facilitate comprehensive coverage.
Last reviewed at:
16 Aug 2021 - 6 min read
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