Critical Management

of COVID-19 in Children

Yogi Prawira
Covid-19 Task Force
Indonesian Pediatric Society
 DISCLOSURE

There is no conflict of interest in this presentation

 Indonesia Current Situation
May 2, 2021

NUMBER of Pediatric Case https://covid19.go.id/peta-

sebaran
12.3% from all cases = 206,304
 Mortality by Age

NUMBER of Pediatric Death Case

1.3% from all death cases = 595

CFR of Pediatric Case

595 from all pediatric cases = 0.28%
Hospitalized Cases in Jakarta

• Hospital fatality rate 0-19 yo = 11/217= 5.1 %

https://www.medrxiv.org/content/10.1101/2020.11.25.20235366v1.full.pdf
Mortality of Children with Confirmed COVID-19:
Report from Indonesian Pediatric Society COVID-19 Data
Registry Pudjiadi AH, et al. (in press)

Most of the dead children had malignancies

(17.3%) as the most common comorbidity,
followed by malnutrition (16.7%), and congenital
heart disease (9%)

There were 62 children who died with no

comorbidities.
 Clinical Severity Classification

Asymptomatic Mild Moderate

Severe Critical

Protokol Tatalaksana COVID-19 Edisi 2. Jakarta: Perhimpunan Dokter Paru Indonesia (PDPI), Perhimpunan Dokter Spesialis Kardiovaskular Indonesia (PERKI), Perhimpunan Dokter Spesialis
Penyakit Dalam Indonesia (PAPDI), Perhimpunan Dokter Anestesiologi dan Terapi Intensif Indonesia (PERDATIN), Ikatan Dokter Anak Indonesia (IDAI). Jakarta; 2020.
Joly BS, et al. Intensive Care Med (2020) 46:1603–1606
Bhaskar S, et al. (2020) The REPROGRAM Consortium Position Paper. Front. Immunol. 11:1648.
Whittaker E, et al. JAMA 2020; 324:259
Centers for Diseases Control and Prevention. 14 May 2020
 a post-infection complication of the virus
rather than acute infection, at least in some children

Feldstein LR, et al. N Engl J Med 2020;383:334-46

 SARS-CoV-2
infection in
Epidemiology individuals median age was 8 to 11
<21 years old years (range 1 to 20 years).
was 322 per
100,000 and

Most patients in
the incidence
healthy condition, but
of MIS-C was
several with obesity
2 per 100,000 and asthma

25-45% black, 30-

40% Hispanic, 15-
25% white, and 3- MIS-C: from the
28% Asian United Kingdom in
April 2020 à
Europe, Canada,
USA, and South
Africa
Feldstein LR, et al. N Engl J Med 2020; 383:334.
Licciardi F, et al. Pediatrics 2020; 146.
Toubiana J, et al. BMJ 2020; 369:m2094.
Whittaker E, et al. JAMA 2020; 324:259.
MIS-C:
Respiratory symptoms
typically reported in
COVID-19 may not be
present in MIS-C.

When present, breathing

difficulties are often
linked to shock, and are
suggestive of heart failure.

European Centre for Disease Prevention and Control.

American Academy of Pediatrics. July 2020.
 PCR and serology were performed:
- 60% positive serology with
negative PCR
- 30–35% were positive on both
tests

39 observational studies (n = 662 patients).

While 71.0% of children (n = 470) were
admitted to the intensive care unit, only 11
deaths (1.7%)

Verdoni L, et al. Lancet 2020; 395:1771

Whittaker E, et al. JAMA 2020; 324:259
Centers for Diseases Control and Prevention. 14 May 2020
Feldstein LR, et al N Engl J Med 2020; 383:334
Godfred-Cato S, et al. MMWR Morb Mortal Wkly Rep 2020; 69:1074. M. Ahmed et al. EClinicalMedicine 26 (2020) 100527
 .

• Clinically shock and GCS 12

• HR 135 beats per minute; BP
70/40mmHg; RR 40 breaths per
minute; temperature 36.5oC, and
prolonged CRT >2 s.
• SpO2 83% (simple mask 5 L/ min).
• No enlargement of the spleen and
• A 6-year-old male with no past medical history,
liver.
with fatigue, looks pale and brought to ER
• Fluid resuscitation and transfusion
• Fever for five days and abdominal pain. There
were performed as pediatric surviving
was no history of cough, breathing difficulties,
sepsis protocol.
bleeding, or rashes.
• Hemodynamic monitoring, inotropic
• No history of traveling or contact with COVID-
agent administration, and subsequent
19 patients.
orotracheal intubation were
• An active child two days before admission, and
performed according to the COVID-19
the symptoms abruptly worsened afterward.
protocol.

• Hb 2.9 g/dL, Hct 9.3 %, WBC 18,103/mL,
lymphocyte 33 %, monocyte 4 %,
erythrocyte 1.13 1012/L, and platelets
counts 213 103/mL
• Peripheral blood smear: normochromic
erythrocytes, anisopoikilocytosis
(ovalocyte, pencil cell) microcytic, and
leukocytic hypersegmentation.
• Albumin 1.96 g/dL, urea 46.2 g/dL, serum
creatinine (S-Cre) 1.15 mg/dL, aspartate
transaminase (AST) 510 U/L, alanine
transaminase (ALT) 173 U/L, potassium 6
mmol/L, sodium 123 mEq/L
• C-reactive protein (CRP) 0.09 mg/dL,
procalcitonin 0.78 ng/mL, Ferritin of
3985 ng/mL.
• BGA revealed pH 6.8, pO2 24.2 mmHg,
pCO2 27.2 mmHg, HCO3 4.8 mmol/L,
TCO2 5.6 mmol/ L, BE –2.78mmol/L and
SO2 17.3 %, lactate dehydrogenase 10.6
mmol/L.
• The rapid test SARS Cov-2 IgM was
reactive and IgG non-reactive
(specificity 95.74 %, sensitivity 69.05 %).
Polymerase Chain Reaction (PCR) of
SARS Cov-2 was negative.
• The IgM anti-dengue was reactive and
the IgG anti-dengue was non-reactive.
• No abnormalities noted on the chest x-
ray
• Initially, patient was diagnosed with a
refractory septic shock that leads to
aggressive fluid resuscitation,
administration of a broad-spectrum
antibiotic, and inotropic agents
according to sepsis guidelines in
children.
• Hemodynamic instability progressed
to the point of multiple organ failure
and passed away within 14 h in the
pediatric emergency unit.
Anggraini Alam

Henderson LA, et al.

Arthritis &
Rheumatology
Vol. 0, No. 0, Month
2020, pp 1–15
 Update Pedoman
Tatalaksana COVID-19
pada Anak
Ikatan Dokter Anak Indonesia
 Outline

§ Skrining Covid-19 pada Anak

§ Triase Covid-19
§ Tatalaksana Covid-19 pada Anak
Skrining Covid-19 pada
Anak
Selain Klasifikasi berdasarkan
Gejala Klinis, pada anak juga
dikenal MIS-C
C OV I D - 1 9 d i a g n o s t i k
Pemeriksaan RT-PCR swab dan virus
Pada kasus suspek dan
probable Covid-19 dengan hasil
swab nasoorofaring negatif,
maka pemeriksaan swab dapat
dilakukan dari rektal/ spesimen
saluran napas bawah
(mis. Sputum)

Pemeriksaan rapid antibodi dan

antigen terhadap SARS-COV-2
Pemeriksaan rapid antibodi dan antigen terhadap
SARS-COV2 diambil dari saluran napas, feses,
maupun spesimen lain seperti plasenta.

Pemeriksaan rapid antibodi positif pada anak

dengan kecurigaan
.

WHO, 16 Desember 2020 : rapid antigen sebagai tes

diagnostik penegakkan kasus covid-19 ,
apabila sarana pemeriksaan RT-PCR terbatas
Triase Covid-19
Tatalaksana Covid-19
 Pemantauan derajat
keparahan pasien pada kasus
anak dengan Covid-19
• Nilai rasio SpO2/FiO2 (SF ratio)
• Indeks saturasi oksigen
(Oxygen Saturation Index/OSI)
• Indeks oksigenasi (Oxygenation Index/OI)
• Kadar FiO2 disesuaikan untuk
Nilai rasio mencapai
SpO2/FiO2 (SF ratio)

target saturasi perifer atau SpO2< 97%

agar validitas penghitungan SF rasio dan
OSI dapat dijaga
• Prediksi perburukan pirau intrapulmonal
dapat dilakukan dengan menghitung dan
memantau AaDO2
• Kriteria P-ARDS yang digunakan sesuai
dengan kriteria Pediatric Acute Lung
Injury Conference Consensus (PALICC)
Indikasi dan prinsip penggunaan NIV atau HFNC
pada kasus anak dengan Covid-19

Anak dengan klinis sesak

(RR >+ sesuai usia) dengan atau tanpa peningkatan usaha nafas atau
work of breathing

Memerlukan suplementasi oksigen untuk

mempertahankan Sp02 > 88% dan OI < 4 atau
OSI < 5

Terdapat infiltrat baru yang konsisten dengan gambaran penyakit

paru akut
 Tata Laksana ARDS
pada Anak dengan
Infeksi COVID-19

Ket. Adaptasi dengan persetujuan komite

consensus PEMVECC 2020
 CPAP/Bilevel NIV OR
Target: SpO2 92-97% with FiO2 < 50%

If not available Titrate PEEP and asess

oxygenation and Low PEEP/FiO2 ratio
hemodynamic
HFNC 2 lpm/kg IBW
Target: SpO2 92-97% with FiO2 < 40%
N
Covid-19 children
Evaluate 60-90’ à - Pplat >32 cmH2O OR - Prone position
NIV Failure Criteria* - Need to reduce flow from the first 24-48
transpulmonary pressure during hours
spontaneous breathing OR - Muscle
Respiratory Failure OR - Need to decreased disynchrony relaxant if
P/F ≤ 200 OR necessary
S/F ≤ 221 Intubate with cuffed ETT
Target: SpO2 92-97% (severe case > 88%) with
FiO2 < 60% pH >7,2
Y Suspect vasoconstriction reflex due
Inhaled Nitric Oxide
to pulmonary hypoxia
Initial ventilator setting:
- Vt 5-7 ml/kg IBW
*NIV Failure Criteria: - Limit pressure (Pplat-PEEP) ≤ 15 cmH2O
1. Decreased LoC OR
2. RR>30x/min age > 5 y.o; >40x/min age
- PEEP∓10 cmH2O or higher in severe case Decreased respiratory compliance HFOV
1-5 y.o, >50x/min age 2-11 mo; - Limit Pplateau ≤ 28 − 32 cmH2O
>60x/min age < 2 mo
3. SpO2 <92% (OR 95% with comorbidities)
4. Increased WoB
Lowest PEEP/FiO2 ratio
5. HR > 120x/min age > 5 y.o
Clinically deteriorated ECMO
Tata Laksana Henti Jantung
pada Anak dengan Suspek
atau Konfirmasi COVID-19
Tata Laksana Koagulopati pada COVID-19
 Lesson learnt: Critical knowledge gap

• The initial impression that paediatric infection is uncommon and

generally mild has been replaced by a more nuance understanding,
with recognition of widening disease spectrum:
• P-ARDS and mechanical ventilation à protective ventilatory strategy
• Cardiac manifestation & hemodynamic compromised
• MIS-C: beyond the lungs (myocarditis, coagulopathy, kidney failure,
gastrointestinal disorder, neurologic manifestation)
• Need much of evidence to build and developed the guideline of
critically ill children with COVID-19
• Every patients were the possibility chance and challenging to treat as
a learning curve
THANK YOU