With the emergence of the third wave of COVID-19, certain guidelines to manage COVID in children have been proposed. 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 comorbid 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.
Wearing a mask is not required in children below the age of 5.
For children aged between 6 and 11 years, wearing a mask is advised in children who know how to use and dispose it safely. However, it should be done under the supervision of the parent or guardian.
There is no relaxation in children above 12 years of age, and they should be encouraged to wear a mask. The recommendations are similar to that of adults.
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:
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 (Accredited social health activists) or MPW (multipurpose workers) 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) COVID vaccines should be administered to the children as per the guidelines of the recommendations of the Government.
An uncomplicated COVID-19 infection that is not accompanied by a superadded bacterial infection usually does not require antimicrobials since COVID-19 is a viral infection. Antimicrobials are recommended only in moderate and severe cases with suspected bacterial infection or in children who develop septic shock. Children with asymptomatic or mild infection of COVID-19 should be administered antimicrobial drugs.
Steroids should not be used in children with asymptomatic and mild COVID-19 infection. It can be administered in children with severe infections but under strict supervision. Steroids should not be started for the first three days as they can delay the viral shedding. Initially, it should be given for 5 to 7 days and then gradually tapered over 10 to 14 days.
The following are the recommended steroids used in the treatment of COVID-19 in children:
Methylprednisolone should be administered at 0.75 mg/kg of body weight, with the maximum dose not exceeding 30 mg in a day.
Dexamethasone dosage is 0.15 mg/kg of body weight, with a maximum dose of 6 mg in a day.
Anticoagulants are not always recommended in children. It should only be given to children who risk developing thrombosis.
Prophylactic use of anticoagulants is used in children in the following situations:
Family or personal history of deep vein thrombosis.
When the child is suspected of thrombosis, then therapeutic doses of anticoagulant are recommended for twelve weeks.
The recommended dosage of Enoxapirin is listed below:
The prophylactic dose of Enoxaparin is 0.5 mg/kg of body weight twice daily.
Therapeutic amount of Enoxaparin 1 mg/kg of body weight twice daily.
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, 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 after wearing 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. Also, before diagnosing MIS-C, bacterial sepsis, tropical fevers like dengue, enteric fever, malaria, and toxic shock syndrome should be ruled out.
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) Vaccination for COVID-19 should be administered to the children after the recommended time.
2) A pulse oximeter should be given at the time of discharge, along with the knowledge about how it should be monitored
3) 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. The children should be brought back to the hospital when there is an incidence of any of the warning signs.
4) 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.
5) Emergency contact numbers in case of any warning signs should be given.
6) Influenza and pneumococcal vaccination may be considered.
7) Appropriate care should be rendered in children who experience organ dysfunction either during the treatment or after recovery from COVID.
8) Also, nutritional support and psychological counseling, if needed, should be given to get past the post-COVID complications.
About 10% of the neonates who are born to COVID-19 positive mothers may be RT-PCR positive for SARS-CoV-2. 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:
10 Mar 2022 - 8 min read
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