COVID- 19 Infection in Children

Covid – 19 infection in children are mostly mild symptomatic or asymptomatic.

Children are 5.8% of total Covid positive patients in India.
COVID-19–associated hospitalization among children 8.0 per 105 population vs 164.5 per 105 in adults
ICU admission rate ranges from 8-20% among hospitalized children
2 main categories of manifestations are observed– 1. Acute Covid -19 infection, 2. Post Covid MIS-C
DISEASE SEVERITY CLASSIFICATION OF ACUTE COVID-19 INFECTION

MILD DISEASE MODERATE DISEASE

Moderate to high grade temperature for 4 days
Fever and or any of the following -
or more and or
1. URTI – Cough, sore throat, coryza, nasal
1.Fast breathing (age based)
obstruction)
≥ 60/min for<2months,
2. Diarrhoea and/vomiting with no ≥ 50/min for 2-12 months,
dehydration/some dehydration with good ≥ 40/min for 1-5 years,
oral intake and good urine output ≥30/min for >5years.

4.Normal activity in between the spikes of 2.SPO2 - <94%

temperature, normal feeding.
5.Loss of taste or smell (>8 year)
3.Diarrhoea and /vomiting with severe
dehydration and decreased oral intake
4. Decreased activity in between the fever spikes
, decreased feeding.

SEVERE DISEASE
CRITICAL DISEASE
1.Severe pneumonia
Pneumonia with any of these, 1.Refractory/super refractory status
-Cyanosis (SpO2< 90%) epilepticus.
- Increased respiratory efforts (grunting,
2.Coma with GCS persistently<8/15.
severe retraction)
2.Lethargy, refusal to feed 3.ARDS
3.Altered sensorium and/ seizure 4.Shock requiring inotropic agents
4.Tachycardia disproportionate to the 5.Myocarditis/Features of Heart failure
temperature.
6.Oliguria/Acute Kidney Injury
5. Hypotension/shock
7.Acute thrombotic Events
6. Fulfils MIS-C Criteria
8.MODS
Evaluate all admitted children with CBC, LFT,
RFT, CRP, d –dimer, Chest x-ray and blood Mild disease with co-morbidity
culture. Repeat after 48-72 hours if clinically
1. Ready access to health care – Continue
indicated.
home care.
Possible tropical infections like malaria, 2. No ready access to healthcare – Admit for
typhoid, dengue, scrub typhus and leptospira observation and evaluation.
to be ruled out Co- morbid conditions - chronic neurological
disorder, chronic respiratory disease,
Selected patients may need echocardiography
congenital heart disease, patients on
and cardiac biomarkers.
imuunosupressive agents,chronic kidney
ABG, Lactate, Ferritin, Procal, in selected disease
patients
 MANAGEMENT
MILD DISEASE
1.Home isolation(17 days from symptom onset)
2.Supportive care
a. Adequate hydration and feeding.
b. ORS for diarrhoea and vomiting.
c. Monitoring of vitals and activity.
d. Vitamin C, Vit D and Zinc may be
considered.(No proven evidence)
3.Symptomatic care:
a. Paracetamol (10-15mg/kg/dose, not more than
5 times/day, minimum 4 hours gap between 2
doses)
b. Anti-histaminic /Saline nasal
drops/Decongestant drops may be considered
to alleviate URTI symptoms.
c. Zinc ± probiotics for diarrhoea.
d. Domperidone/Ondansetron for vomiting.
4.Danger signs to be explained in details
5.Report to health care facilities if danger signs
develops.
Danger signs – Any one of the following.
Persistent fever for ≥ 5 days, Reappearance of fever,
Reduced oral intake, Decreased urine output or signs of
dehydration, becomes lethargic, Shortness of breath and
SpO2 <94% .
**
Inj Dexamethasone 0.15mg/kg/day as a single dose(maximum 6mg/day) for 5 to 14 days according to severity of the
disease and clinical response.
❖ Equivalent dose of other [ Prednisone (1 mg/kg/day, up to 40 mg/day)/Methylprednisolone (0.5-1 mg/kg in 2
divided doses ) steroids may be given.
Oxygen Delivery–
Nasal Prong -Flow range 1-5 L/min
The formula is FiO = 20% + (4 × oxygen litre flow).
2 Enoxaparin –
Simple Oxygen Mask - delivers an FiO2 of 40-60% at 5-10
L/min
Non-Rebreathing Mask – FiO2 90% at flow rate -8-10L/min
MODERATE DISEASE
1.Hospitalisation in Isolation/dedicated Pediatric
covid ward settings.
2.Supportive Care
a. Adequate hydration and feeding. May need iv
fluids and /or Nasogastric feeding.
b. ORS/IV fluids according to standard protocol.
c. Zinc ± probiotics to be considered for
diarrhoea.
3.Symptomatic Care:
Oral Paracetamol (10-15mg/kg/dos, (not more than 5
times/day, minimum 4 hours gap between 2 doses)
Domperidone/Ondansetron for vomiting.
3.Oxygen therapy: Give supplemental oxygen
through nasal prongs/ face mask if oxygen saturation
is less than 94 %.
4.MDI with Salbutamol and/Ipratropium may be
considered in patients with pre-existing Reactive
airway disease who presented with wheezing.
5. Avoid Nebulization
6. Systemic steroid: To be started if SPO2<94%.*
7. Consider awake proning in children > 8 yrs.
8. Remdesivir on case-to-case basis (respiratory)
9. Empirical antibiotics if bacterial co-infection is
suspected.
Indication of LMWH – Patient with moderate to severe
disease requiring oxygen and D-dimer > 2000 ng/ml.
< 2 months - 1.5 mg/kg 12 hrly SC
>2 months – 1 mg/kg 12 hrly SC
SEVERE DISEASE
1.Admit in Pediatric covid HDU/ PICU settings
2.Supportive Care
Appropriate hydration, if needed isotonic fluid
boluses.
Start early enteral feeding
3.Symptomatic Care:
Syrup Paracetamol through ng tube/IV paracetamol
for fever
Control of seizure according to standard protocol
3. Oxygen therapy-Start with NRBM (10L/min)
followed by HHFNC with a flow of 2L/kg and fio2 of
40%.Target SPO2 92to 96%.Titrate according to
response.(increase flow by 0.5L/kg above 12kg)
If no response to HHFNC, step-up to NIV/Invasive
mechanical ventilation.
Consider awake proning in children > 8 yrs.
4.Systemic steroid: To all patients with severe disease
with respiratory presentation. *
7.Remdesivir: To all patients with severe disease
with respiratory presentation. **
8.Emperical broad spectrum antibiotic according to
local protocol
9. Consider IVIG if fulfils criteria of MIS-C
Antimicrobials – Amoxicillin/Co-
Amoxiclav/Ceftriaxone – if bacterial co-infection
suspected.
**Remdesivir
3.5kg to 40 kg: 5mg/kg on day 1 and then 2.5mg/kg from
day 2 to day 5.
>40 kg: 200mg on day 1 and then 100mg once daily
fromday 2 to day 5
To be used within 10 days of onset of Symptoms
Contraindicated if ALT/AST> 5 times normal and /or
Creatinine Clearance <30 ml/min
CRITICAL DISEASE
1. Admit in Covid PICU settings
2.Supportive Care
Appropriate hydration, if needed isotonic fluid
boluses. Maintain euvolumia.
Restrictive maintenance fluid for Severe ARDS or
Myocardial dysfunction
3.Symptomatic care
a. Control of seizure according to standard
protocol
b. Elective intubation if coma/GCS persistently
below 8/Super refractory status epilepticus.
4. Respiratory support: HHFNC/NIV may be tried for
mild ARDS. For failed HHFNC or moderate to severe
ARDS invasive mechanical ventilation.(PARDS
protocol)
If poor response consider proning ,HFOV,ECMO.
5. Systemic Steroid*
6. Remdesivir**
7. Tocilizumab (on case-to-case)
7. SHOCK- adequate istonic fluid boluses(10‐
20 ml/kg over 30‐60 min,).Intropic agents for fluid
refractory shock. Adrenalin Infusion for cold shock
and Nor adrenalin infusion for warm shock.
8.Manage AKI/Myocarditis/HLH as per protocol
9. Empirical broad spectrum antibiotic according to
local protocol
10.Consider IVIG if fulfils criteria of MIS-C
DISCHARGE CRITERIA
Patient is out of all organ support or in pre-morbid
condition
Marinating Saturation >94% in room air for 24 hrs
Afebrile for 72 hours.
Accepting oral feed well.
Mother is Confident to take care at home
No repeat testing is required in Mild to moderate disease
Follow up after 1-2 wks followed by 4-6 wks.
 MANAGEMENT OF MIS-C(Multisystem Inflammatory
syndrome in Children) associated with SARS-COV-2

Diagnostic Criteria for MIS‐C

ALL 6 CRITERIA MUST BE MET

1.Age 0- 19 years
2.Fever for ≥3 days

3.Clinical signs of multisystem involvement (at least 2 of the following):

• Rash, bilateral nonpurulent conjunctivitis, or mucocutaneous
inflammation signs (oral, hands, or feet)
• Hypotension or shock
• Cardiac dysfunction, pericarditis, valvulitis , or coronary
abnormalities (including echocardiography findings or elevated
troponin/BNP)
• Evidence of coagulopathy (prolonged PT or APTT; elevated D-dimer)
• Acute gastrointestinal symptoms (diarrhoea, vomiting, or abdominal
pain)

4.Elevated markers of inflammation (eg, ESR, CRP, or procalcitonin)

5.No other obvious microbial cause of inflammation.

6.Evidence of SARS-CoV-2 infection(Any one of the following)

– Positive SARS-CoV-2 RT-PCR
– Positive serology(SARS CoV-2 IgG positive)
– Positive antigen test
– Contact with an individual with COVID-19
 PHENOTYPIC VARIATIONS AND MANAGEMENT

1. SEVERE MISC/MISC with SHOCK/MISC with LIFE

THREATENING MANIFESTATIONS/MISC with MODS

PRESENTATION: Rx
1. Judicious fluid bolus and early inotrope
➢ CBC(lymphopenia,neutrophilia,
initiation in case of shock.
thrombocytopenia,anemia
➢ Elevated Inflammatory markers(CRP, 2. Intravenous Immunoglobulin (IV Ig)
ESR, Ferritin, Procalcitonin, Fibrinogen, 2gm/kg (maximum 100 gm) over 8-12
IL-6,d-dimer) hours.**
➢ Elevated cardiac Markers(NT –PRO 3.STEROID:IV Pulse Methylprednisolone (10-
BNP, Troponin –T) 30mg/kg/day for 3-5 days) followed by oral
➢ Altered coagulation Profile(Elevated d- Prednisolone 2 mg/kg/day and then taper
dimer, PT,APTT) over 4 weeks)**
➢ Altered LFT, RFT
➢ ECG-Tachycardia, ST wave changes, low 4.Broad Spectrum antimicrobial according to
voltage. local protocol until infections ruled out.
➢ Echocardiography-* 5. Aspirin: 3-5 mg/kg/day (maximum
o LV Dysfunction 75mg/day) for 8 weeks and then
o Coronary artery changes, individualised. Contraindicated if platelet <
o Mitral regurgitation 80,000 or bleeding.
o Pericardial effusion 6. LMWH- Enoxaparin 1mg /kg twice daily SC
➢ CXR-normal, pneumonic patches, if
pulmonary edema, ARDS, Cardiomegaly)
➢ Negative Tropical infection screening i. Any documented thrombotic events
(Malaria, Dengue, Enteric fever, scrub ii. LVEF<35 %
typhus, Blood culture). iii. Critically sick child with d –dimer>2000
➢ Evidence of SARS COV-2 Infection ng/ml (soft indication, to be individualised).
present

* Repeat Echocardiography as clinically

indicated or every 2-3 days until myocardial
dysfunction or coronary artery size stabilizes,
then at 2weeks and again at 6-8 weeks.

➢ ** In patient with significant LV dysfunction, if there is a concern that the patient will not
tolerate the volume load of the full dose of IVIg in a single infusion, it can be given in
divided doses slowly over two to three days under close monitoring
➢ A second dose of IV Ig and/or Biologics to be considered as rescue therapy for refractory
disease. Choices of biologics are
o Tocilizumab 4 to 8 mg/kg/dose or
o Infliximab 5mg/kg IV or
o Anakinra 2‐10 mg/kg/dose (max 100 mg/dose) SQ/IV q6‐12h
 2.MISC with predominant Kawasaki Disease like feature.

Presentations :
➢ No Shock
➢ No life threatening features
➢ No organ failure.
➢ Predominant mucositis, conjunctivitis
and cutaneous features
➢ Fulfils the diagnostic criteria of
Complete/Incomplete Kawasaki
Disease
➢ ECHO- No LV dysfunction/Mild LV
dysfunction. Coronary artery changes
may or may not be there*
➢ Inflammatory markers are elevated
➢ Fulfils MISC criteria
➢ Negative Tropical infection screening
(Malaria, Dengue, Enteric fever, scrub
typhus, Blood culture).
Rx
Intravenous Immunoglobulin - 2gm/kg
(maximum 100 gm) over 8 -12 hours.
+/-
STEROID: Low dose Methylprednisolone
(1-2mg/kg/day for 3-5 days)followed by
oral Prednisolone 2 mg/kg/day and then
taper over 2 weeks)**
3. Aspirin :3-5 mg/kg/day (maximum
75mg/day) for 8 weeks and then
individualised. Contraindicated if platelet <
80,000 or bleeding.
5. LMWH- Enoxaparin 1mg /kg twice daily
SC if
o Any documented thrombotic events
o Giant Aneurysm(Z score>10)

➢ Evidence of SARS COV-2 Infection

present

*Repeat Echocardiography as clinically indicated Resistant to Initial management –

or every 2-3 days until myocardial dysfunction or
1. Repeat IVIG ; OR
coronary artery size stabilizes. Thereafter at 2
2. Tocilizumab 4 to 8 mg/kg/dose or
weeks and again at 6-8 weeks. Typically Kawasaki
Infliximab 5mg/kg IV or
disease protocol is being followed in this
Anakinra 2‐10 mg/kg/dose (max 100
phenotype for follow up. mg/dose) SQ/IV q6‐12h

**Concomitant use of IVIg along with steroid is preferred in high risk cases like

➢ Age less than 1 year

➢ Any coronary artery Z score more than 2.5 at presentation .

Pulse Methylprednisolone may be needed if this phenotype fulfils the diagnostic criteria
of Macrophage Activation Syndrome(MAS).
 3.MILD MISC/FEBRILE INFLAMMATORY STATE

RX
PRESENTATION: Wait & watch for 48 hours and rule out
✓ No Shock infectious etiology.
Immunotherapy if clinical status worsens or
✓ No life threatening features
no defervescence with persistent raised
✓ No organ failure. inflammatory markers beyond 48 hours

✓ ECHO- No LV dysfunction. First line: Low dose IV Methylprednisolone

1-2mg/kg/day for 3 to 5 days followed by
✓ Does not fulfil Kawasaki Disease oral Prednisolone 2mg/kg/day and then
Criteria. taper off by 2 weeks.

✓ Inflammatory markers are elevated Second line: If non responsive then

Intravenous Immunoglobulin (1-2gram) may
✓ Fulfils MISC criteria be considered.
✓ Negative Tropical infection screening ➢ Low dose Aspirin only if coronary
(Malaria, Dengue, Enteric fever, scrub Involvement.
typhus, Blood culture).
➢ LMWH only if documented
✓ Evidence of SARS COV-2 Infection thrombotic events
present

Thrombo-prophylaxis (for Adolescence, Obesity, Bed ridden): 0.5mg/kg SC

twice per day of ENOXAPERIN may be used in any above phenotype.

Second line(Tier II) investigations (D-dimer, Fibrinogen,Procalcitonin,IL-6,NT-ProBNP ,Troponin,COVID IgG )

to be done only after a positive screening of first line investigations(Tier I)(CBC, CRP,LFT,RFT,Electrolytes)in
a suspected patients in all phenotypes. .
Positive screen (both of these should be present):
1. CRP > 5 times baseline value and/or ESR > 40 mm per hour;
2. At least one of these:
❖ ALC <1000/μL,
❖ Platelet < 150,000/μL,
❖ Na < 135 mEq/L,
❖ Neutrophilia
❖ Hypoalbuminemia
COVID- 19in children FAQ -
1. Is there increase in infection in children during second wave?

Yes.

According to the ICMR data children comprise 5.8% of total Covid 19 infection in the 2nd
wave in comparison to 4.2 % in first wave. Though percentage wise it's not looking huge,
but looking at the increase in total number of adult patients’ total number will be
considerably higher in children as well.

2 What are the common presenting symptomsin children?

85-90% of children are mild symptomatic or asymptomatic.

Among symptomatic children common clinical features are in combination of the following

• Fever low to moderate grade persisting for 2 to 4 days.

• Headache, myalgia, fatigue, tiredness, coryza, cough, sore throat, rapid breathing.
• Diarrhoea, vomiting, abdominal pain
• Poor feeding in an infant, loss of taste or smell (>8 year)
• Rash, conjunctival congestion, mucositis, shock

3. How do children acquire infection?

• Most commonly from close contact of infected adult members of the family.
• Visiting social gatherings and public places, where covid appropriate behaviour
violated.
• From other children due to Group play, coaching classes or other gatherings in a
closed space.

4.How can I triage patients in Clinic/OPD ?

• We should never allow more than 5-10 people at any given time waiting for their
turn in the OPD halls.
• Stagger the patients. Patients need to sit in the OPD at their allotted time slot.
• Discourage healthy patients from coming to the clinic for routine check-up.
• Allot separate time for routine immunizations for healthy children.
• Among the mildly sick patients allot a different time& a separate place to sit for
patients with features of a respiratory (flu-like) illness (patient identification &
triaging).
• Encourage your patients to call up over the phone for any mild respiratory illness.
Many can be treated in home care over Tele-medicine.
5. If a member of the family is positive, should we screen all children, even if
asymptomatic?

Not required for healthy asymptomatic children. Advise tests for asymptomatic children
with comorbidity on Day 5-7 of exposure.

6. When and whom to test in case of children?

The criteria for testing are still evolving.

• Symptomatic children or asymptomatic children with comorbidity who came in

contact with a confirmed case within last 14 days.
• All sick or critically ill patients requiring hospitalization irrespective of contact
history.
• Patients with Influenza like illness or diarrhoea continue for more than 3 days
without any improvement and no definite contact history.

7. What test to be done for diagnosis?

• COVID-19 RT-PCR is the gold standard with good sensitivity and specificity in adults.
Sample may be collected from nasopharyngeal swab, throat swab, tracheal aspirate
or bronchoalveolar lavage. There is no published literature outlining the sensitivity
and specificity of RT-PCR in children.

8. The Child has Covid Symptoms and positive contact history but RT-PCR negative – Why?

It is possible as it is difficult to get cooperation from smaller children to get adequate

respiratory sample for RT-PCR testing. That may produce false negative results. In that
situation you can repeat the test once after 48 hours if signs and symptoms persist or
deteriorate.

9. Is there is role of any prophylactic treatment to prevent corona in children?

• Only strict precautions of Hand washing, proper Mask, Social distancing can prevent
it.
• Avoid attending public functions, avoid social gathering, avoid group play are only
ways we can prevent corona in children and household.
10. Various domestic situations:

a. Mother and child both positive: let child be with mother unless mother is sick and
hospitalized. In infant, continue breast feeding as far as possible and feasible.

b. Mother positive and child negative: mother can take care of child if no better option
available for child. Mother has to follow best possible SMS (sanitization, proper mask, social
distancing) practices. Mother can breastfeed with all precautions.

c. Child positive parent negative: Still parent can take care of the child in or out of the
hospital. If the child need hospitalization for physical care and mental support of the child
mother or other responsible care giver should be counselled to stay in the hospital after
providing all informed choices. In this situation hospital should provide personal protective
equipment (disposable gowns, cap, mask, face-shield) to the mother. Full PPE is not
practically feasible to wear whole day.

d. Avoid leaving children with Covid suspect status with grandparents. Elderly people are at
very high risk of serious disease and unless child’s status is definitely corona negative child
should not be left with grandparents.

11. Should I advise mask to be worn for children?

Yes, masks need to be worn by all children above the age of 6 years (WHO
recommendation). IAP Recommends mask for children above 2 yrs. Children less than 2
years need not use the mask due to safety reasons.

12. What are parameters I should ask to monitor for child in Home Care?

• Temperature. Advise parents to maintain Temperature chart and trend.

• Activity and general wellbeing in between febrile periods of the child
• Passage of Urine and Signs of dehydration
• Persistent cough and shortness of breath
• SpO2 by Pulse oximeter
• Amount of oral intake
• Appearance of new symptoms

13. What are the Red Flag Signs ?

• Persistent fever for > 4 days

• Reappearance of fever
• Any new onset symptoms
• Reduced oral intake to 50% of usual intake
• Decreased urine output or other signs of dehydration
 • Become Lethargic
• Shortness of breath and Oxygen saturation < 94% in room air.

14. Measuring Oxygen saturation in children by finger pulse oximeter – is it reliable?

There are difficulties in interpreting pulse oximeter reading in children below 6 years due to
improper attachment, movement of limbs, keeping it fixed for at least 2-3 min. Be vigilant of
these facts and ensure that good plethysmograph wave is visible before coming to a
conclusion. If possible, ask parents to show attachment of pulse oximeter by video calling.

15. Is there any role of CT Chest in diagnosis and treatment of Covid infection in children?

There is no role of CT scan in diagnosis of Covid infection in children. It also does not help
in treatment as typical lung involvement found in adults are not common finding in children.
Also, logistic issues of transport and administration of sedation are there. However, it may
be considered to answer a specific clinical question in acute settings like worsening clinical
course or pulmonary thromboembolism.

16. In adult patients Low molecular weight heparin is used as prophylaxis in moderate
Covid – Should it be used in children as well?

No. In children we use as therapeutic option when D-dimer is > 2000 ng/ml along with
pulmonary involvement leading to oxygen requirement.

17. What about medicines like Azithromycin, Ivermectin, Doxycycline, HCQ, Ayurvedic,
Homeopathic etc.?

There is no scientific evidence to use these drugs for Corona treatment as such in adults or
paediatric population and few of these drugs are used when adults are hospitalized with
serious disease. There is no role of these drugs in home treatment.

18. When we can advise routine immunization in a child recovered from Covid?

• Any patient fully recovered from COVID-19 can be vaccinated at any time if their
clinical condition allows.
• Defer 3 months if the child receives IVIG. Wait 9 months before MMR and Varicella
vaccine in IVIG administered.
19. Covid vaccine in children – Where do we stand ?

The Pfizer vaccine already is cleared for use starting at age 16. That means some high
schoolers could get this vaccine.
Pfizer and Moderna both have completed enrollment for studies of children ages 12 and
older, and expect to release the data over the summer.If regulators clear the results,
younger teens likewise could start getting vaccinated once supply allows.
The Pfizer–BioNTech vaccine in children - trial under 12 has started enrolling from late
March.

20. A lactating mother seeks advice regarding taking shots of Covid Vaccine – What will be your
advice?

Till now no definite data available in pregnant and lactating mother regarding safety of
Covaxin or Covishield. However lactating mothers can be offered vaccine after providing
informed choice if she meets vaccine prioritize group such as health care worker. As per
current understanding benefits outweighs risk.

21. Post-Covid lung fibrosis – is it common in children?

In contrast to the adult counterpart this entity is very rarely reported in literature. Only one case
report till now.