PEDIATRICS (019) COVID-19 IN CHILDREN PEDIATRICS SIRMATA 2024

(019)
● COVID-19 IN CHILDREN
DR.
● ROCHELLE CARTA | 05/23/23 [LEC]
●

of the coronavirus disease 2019 (COVID-19) pandemic has

OUTLINE greatly impacted the lives of many all over the world.
● The epidemiology of COVID-19 in the pediatric population has
I. COVID-19 IN CHILDREN been challenging to establish for several reasons, including
the high prevalence of asymptomatic infection and differences
A. Global Situation in testing rates between children and adults. Studies have
II. VIROLOGY OF SAR-COV2 found that compared with adults, children may have similar or
A. Key Definitions higher incidence rates of SARS-CoV-2 infection but more
B. Pango Lineage System frequently experience asymptomatic infection or less severe
symptoms.
C. Incubation Period ● What are the expected auscultatory findings in patients with
D. Transmission covid? Patients can have clear breath sounds, rales,
E. Risk Factors wheezes, crackles.
III. CLINICAL MANIFESTATION OF COVID-
19 IN CHILDREN A. Global Situation
A. Clinical Manifestation ● Globally as of May 24, 2023- 766,895,075 confirmed cases of
Covid 19, including 6,935,889 deaths
IV. SEVERITY AND UNDERLYING MEDICAL ● As of May 22, 202313,354,202,412 vaccine doses have been
CONDITION administered
A. Age ● In Philippines, from January 3, 2020 to May 25,2023-4,
133,644 confirmed cases of Covid 19 with 66,466 deaths
V. COVID-19 VACCINES UNDER EUA ● As of March 8, 2023 a total of 170,690,206 vaccine doses
VI. SARS-COV2 TESTING have been administered
A. Testing of Children
B. Testing in Newborns CASES FOR REGION I:
● 148,042 cases
C. Testing in Schools ● +38 added on 5/25
VII. LABORATORY AND RADIOGRAPHIC ● Active cases: 391
FINDINGS ● Recovered: 144,431
● Died 3220
VIII. MULTISYSTEM INFLAMMATORY ● As the total number of reported cases increase globally, the
SYNDROME IN CHILDREN (MIS-C) number of pediatric cases have also steadily increased over
IX. MANAGEMENT OF ILLNESS the past two years
X. POST-COVID CONDITIONS (PCS) SALVACION STUDY- Surveillance and Analysis of COVID 19
XI. CONSIDERATIONS FOR ROUTINE in Children Nationwide
PEDIATRIC CARE DURING THE ● aims to collect retrospective and prospective data on the
epidemiologic profile, clinical and laboratory features,
COVID-19 PANDEMIC treatment and outcome of COVID 19 in children through a
A. US centers for Disease Control and pediatric covid 19 registry
Prevention case ● Doctor Salvacion is the PIDS president who died due to Covid
B. Caregiver 19.
C. Hygiene and Sanitation
D. Home Therapies
E. Emotional and Mental support
F. Monitoring
G. Pts. with Moderate, Severe or
Critical Symptoms
H. In-Patient management
I. Diagnostics
J. Imaging Studies
K. Ultrasonographic features seen in
COVID 19 pneumonia
XII. REFERENCES
XIII. TEST YOUR KNOWLEDGE
XIV. APPENDIX

I. COVID-19 IN CHILDREN
Figure 1. Salvacion COVID-19 profile
● The emergence of the novel coronavirus SARS-CoV-2 and
the subsequent declaration by the World Health Organization
●

PREPARED BY: CMED 3EF Page 1 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN
Figure 2. Salvacion COVID-19 manifestations and
management
INCIDENCE
● The epidemiology of Covid 19 in the pediatric population
has been challenging to establish for several reasons:
○ *high prevalence of asymptomatic infection
○ *differences in testing rates between children and adults
II. VIROLOGY OF SARS COV-2
Figure 3. Classification Scheme of Coronavirus
SARS-CoV-2 is a member of a large family of viruses called
coronaviruses. These viruses can infect people and some
animals. SARS-CoV-2 was first known to infect people in 2019.
The virus is thought to spread from person to person through
droplets released when an infected person coughs, sneezes, or
talks.
A. Key Definitions
● Mutation- single change in a virus's genome
● Lineage- group of closely related viruses with a common
ancestor
● Sublineage- define a lineage as it relates to being a direct
descendant of a parent lineage. Eg. BA.2.75 is a
sublineage of BA.2.
● Variant- a viral genome that may contain one or more
mutations
● Recombination- a process in which the genome of 2 SARS
CoV2 variants combine during the viral replication process
to form a new variant that is different from both parent
lineages.
● This may occur when a person is infected with two variants
at the same time. The lineage that results from
recombination is called recombinant
● VOl-variant of interest
● VOC-variant of concern
● VOHC-variant of high consequence
● VBM-variants being monitored
PREPARED BY: CMED 3EF
SIRMATA 2024
B. Pango Lineage System
● hierarchical like a family tree
● lineages are evolutionary descendants of a parent lineage
● named using an alphabetical prefix and numerical suffix
Table 1. SARS COV-2 LIST OF VARIANTS
VBM
● lineages whose data indicates there is a potential or clear
impact available medical countermeasures
● lineages that cause more severe disease or increased
transmission but are no longer detected
● lineages previously designated as a VOI, VOC or VOHC
that are currently circulating at very low levels in the United
States
VOC
● increase in transmissibility
● more severe disease
● significant reduction in neutralization by antibodies
generated during previous infection or vaccination
● classifications may change over time based on the
information available
C. Incubation Period
● the incubation period for COVID-19 is thought to extend to
14 days, but studies suggest that incubation periods may
differ by variant of the virus
● Rarely, symptoms appeared as soon as 2 days after
exposure. Most people with symptoms had them by day 12.
● study conducted during high levels of Delta variant
transmission reported a mean incubation period of 4.3 days
but the mean incubation periods of other variants, including
Alpha and Beta was 5 days
● studies performed during high levels of omicron variant
transmission reported a median incubation period of 3-4
days
● Be familiar with the family, subtypes, variants of Covid 19
infection
D. Transmission
● COVID-19 is primarily transmitted through inhalation of
infected respiratory droplets, or by contact of the mucosal
surfaces of the eyes, nose and mouth after touching
contaminated objects and surfaces.
● No breast milk transmission so no need for mothers to be
separated from the babies but they must wear a mask
● Airborne transmission may also occur in certain situations
where viral particles are aerosolized through aerosol-
generating procedures such as 'non-invasive positive
pressure ventilation (NIPPV, BiPAP and CPAP)
endotracheal intubation and extubation, cardiopulmonary
resuscitation ' (CPR), open suctioning of airway secretions
frequency oscillatory ventilation, tracheostomy, chest
Page 2 of 27
 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

physiotherapy, nebulizer treatment, sputum induction, ● The two most common manifestations are fever (59.1%)
nasogastric tube placement and bronchoscopy. and cough (55.9%).
● Other possible modes of transmission have been reported ● No symptoms were seen in 19.3% of infected children.
in literature. Prolonged viral shedding in the stool of
infected children has been documented, but there is limited
evidence at present on whether viral RNA shed in stools is
infectious and whether fecal viral shedding plays a role in
the dissemination of infection.
● Recent published data have shown evidence of
transplacental transmission of SARS-CoV-2 from mother
to infant, despite prior claims that vertical transmission
does not occur.
● Evidence of placental infection with SARS-CoV-2 was seen
in a mother infected with COVID-19, with neonate also
testing positive for COVID 19 on nasopharyngeal and
rectal swab RT-PCR. Reiterating that we don’t separate the
baby from the mother and emphasizing on wearing a mask
and handwashing.
● A systematic review on vertical transmission of COVID-19
also concluded that vertical transmission of infection
cannot be excluded in several of the reported cases.
Transmission via breast milk has also been investigated, Table 2. Clinical Symptoms of COVID-19 in children
and although viral RNA particles have been isolated in
breastmilk, the viability of these viral particles have not A. Clinical Manifestation
been proven and transmission via breast milk has yet to be
● MC symptoms: fever and cough
confirmed. Babies can still breast feed. According to the
● sore throat, rhinorrhea, headache, fatigue, shortness of
Philippines Society of Newborn Medicine, the current
breath, or gastrointestinal symptom
literature on COVID-19, breast milk is not considered a
● If the physician on duty is highly suspicious of COVID
transmission vehicle. The present SARS-Cov-2 pandemic
infection, they should request for RAT
requires the promotion of breastfeeding with proper health
● some case studies conducted during high levels of
and hygiene approach. With breastfeeding there’s
Omicron variant transmission have reported a substantial
contamination through air and via contact with the
increase in croup during a decline in the prevalence of all
respiratory secretions of the infected mother who should be
other respiratory viral pathogens known to cause croup
wearing face masks at all times and should be observing
● testing for SARS-CoV-2 should be considered even with
handwashing before and after servings.
mild symptoms
● Children have been shown to be infected via close contact
● The most common symptoms of COVID-19 in children are
with people infected with SARS-CoV-2. In a study on the
fever and cough, but many children can experience sore
spread of COVID-19 in family clusters with confirmed
throat, rhinorrhea, headache, fatigue, shortness of breath,
COVID-19 infection in children, 79% of households had an
or gastrointestinal symptoms, including nausea, vomiting,
adult family member diagnosed with COVID19 before the
or diarrhea. Some case studies conducted during high
onset of symptoms in the COVID-19-infected child. In only
levels of Omicron variant transmission have reported a
8% of households did the child develop symptoms first
substantial increase in croup during a decline in the
before any other household contact.
prevalence of all other respiratory viral pathogens known
● This supports earlier findings that children are mainly
to cause croup.
infected within familial clusters. Evidence has also shown
● The signs and symptoms of COVID-19 in children can be
that children with COVID-19 are capable of transmitting the
similar to those of other infections and noninfectious
disease to adults and to other children.
processes, making symptom-based screening for
● Yet despite these findings, the exact role of children in the
identification of SARS-CoV-2 in children particularly
extent of disease transmission has yet to be clearly
challenging15. Testing for SARS-CoV-2 should be
determined and would need to be further investigated.
considered, even in children with mild symptoms.
E. Risk Factors
Several risk factors have been identified that predispose children
to COVID-19 infection. In the systematic review by Hoang et al.,
a cohort of 655 patients were identified to have the following
underlying conditions that predisposed the patients to COVID-
19 infection:
● Immunosuppression (30.5%)
● Respiratory conditions (21%)
● Cardiovascular conditions (13.7%)
● Complex congenital malformations (10.7%)
● Hematologic conditions (3.8%)
● Neurologic conditions (3.4%)
● Obesity (3.4%)
● Prématurity (3.4%)
● Endocrine/metabolic conditions (2.1%]
● Renal conditions (1.7%)
● Gastrointestinal conditions (0.5%)

III. CLINICAL MANIFESTATION OF COVID-19

IN CHILDREN
● A systematic review of children with COVID-19 by Hoang
et al. has described the most common symptoms seen.

PREPARED BY: CMED 3EF Page 3 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

V. COVID-19 VACCINES UNDER EUA

(Emergency Used Authorization)
mRNA Vaccines
1. moderna COVID-19 vaccine, bivalent
2. pfizer-biontech COVID-19 vaccine, bivalent.
Table 3. Theories regarding Susceptibility of Children to pfizer previously was monovalent but is not used anymore
COVID-19 because it should be bivalent.

Protein Subunit Vaccine

IV. SEVERITY AND UNDERLYING MEDICAL 1. novavax COVID-19 vaccine, adjuvanted
CONDITIONS
● most children- asymptomatic or with mild illness VI. SARS-COV2 TESTING
● some are at risk of developing severe illness-
hospitalization, ICU, placement on mechanical ventilation
and even death
● Studies have found that some underlying medical
conditions-obesity, diabetes, cardiac, lung and neurologic
disorders and medical complexity increase the risk of
severe outcomes from covid-19 and having more than one
comorbidities is associated with increased risk of severe
illness. It's the same with adults, if the child has
comorbidities, his or her symptoms may be severe.

A. Age
● Studies have found that age may also be associated with
the risk of severe illness and evaluation of
● surveillance data from children >7days old and <18yo
reported that infants made up a disproportionate number of
severe acute Covid-19 cases
● Similarly, a study of hospitalization rates 0-17yo during the
Omicron period were four times as high as rates during the
peak of the Delta period and children aged 0-4 yo
experienced the largest increase of hospitalization rates.
● The rate of hospitalization among infants may be increased
by the greater need for evaluation in young infants with
fever, prematurity and the propensity for very young
children to develop viral co-infection and an eligibility for
vaccination among others.
● In addition to individual risk factors the covid 19 variants is
circulating at the time of infection could have an impact on
disease severity
● compared to prior periods, studies among children aged 0-
17 years conducted during the delta variant predominant
period found increased rates of hospitalization
● Studies that compared the delta to the omicron
predominant period found increased rates of Figure 4. Diagnostic Testing for Covid-19
hospitalization during the omicron predominant period but
pediatric patients experienced less severe disease during How do we test Covid-19 infection?
omicron predominant period than in previous waves. Can molecular based assays:
you still remember during omicron, there were alot of
cases. RT-PCR
● studies have found that vaccination is effective at reducing ● Nucleic acid amplification tests (NAATS) using the RT-
risk of hospitalization in children and adolescents and PCR (remind you that it means Reverse transcriptase-
critical illness in adolescents Polymerase Chain Reaction).
○ during omicron2 dose mRNA vaccine decreased rapidly ● Share ko lang when we had our revalida. Yes the student
symptomatic infection got it about the covid-19 however when we asked what RT-
○ And among adolescents vaccine effectiveness PCR means? So um.. We were just disappointed that RT
increased after a booster dose. means so that is reverse transcriptase nuh.
○ completion of a 2 dose mRNA Covid 19 vaccination ● And this is the standard method for diagnosing SARS CoV-
series during pregnancy was associated a with a 2 infection.
reduced risk of hospitalization for Covid-19 ● Reading of the table above Diagnostic testing.
○ Including for critical illness among infants younger than
6 months of age. Rapid Antigen Test
● Detect the presence of your viral proteins or your antigens
PRE EXPOSURE PROPHYLAXIS expressed by the SARS CoV-2 in a sample usually
● Evoshield-monoclonal antibody not currently authorized for obtained again usually through your nasal or your
emergency use. nasopharyngeal swab after collection sample is placed to
an extraction, you know this already. Many of you went for
an antigen-test.
● Before, it took time and we wait for 7 days for the RT-PCR
result to come out but now after 24 hours we have the result
usually for now.

PREPARED BY: CMED 3EF Page 4 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Antibody or Serologic test ● A study of over 10,000 hospitalized children found that
● There are specific antibodies your IgM and IgG that are lower blood pressure, higher heart and respiratory rate and
produced after SARS CoV-2 infection and can be abnormal markers of inflammation including D-dimers and
detected by a variety of methods from the blood like your ferritin were associated with severe illness in children
ELISA (Enzyme-linked immunosorbent assay) or your ● Chest radiographs and computed tomography images of
kenny luminescence assay children with COVID-19 are frequently normal
● Determining unique viral target proteins to reduce cross ● Chest radiographs-patchy infiltrates or opacities
reactivity to other coronaviruses is a challenge and can ● Most common CT finding- patchy ground glass opacification
affect test sensitivity and specificity.
● Antibodies may be utilized in the following situations Table
reading. Severity Definition
● There was a time then when doctors used antibody
testing for them to assess the need for vaccination if they
Mild No ● Symptomatic patients meeting
have produced antibodies but this is not recommended and
disease pneumonia the case definition for COVID-
then it drastically faded.
19 without evidence of viral
pneumonia or hypoxia.
What about the Ancillary Test? We have your:
● CBC
Moderate Pneumonia ● Child with clinical signs of non-
● Chest x-ray
disease severe pneumonia (cough or
● CRP (C-reactive protein) and
difficulty breathing + fast
● ESR (Erythrocyte sedimentation rate) your inflammatory
breathing and or chest
markers. (Most commonly used inflammatory markers are
indrawing) and no signs of
CRP, ESR, and PV /plasma viscosity).
severe pneumonia, including
Sp02 ≥ 95% on room air
A. Testing of Children ● Tachypnea (in breaths/min);
● Viral tests including nucleic acid amplification tests respiratory rate differs at different
(NAATS) (RT-PCR) and antigen tests are recommended to age
diagnose acute infection with SARS-CoV-2. Testing is ○ 3 months old to 12 months
important to identify infection and prevent transmission of old: ≥ 50 breaths per minute
COVID-19. People who have symptoms of COVID-19 and ○ 1 year old to 5 years old: ≥
close contacts of people with COVID-19 should be tested. 40 breaths per minute
○ 5-12 years: ≥30 breaths per
minute
B. Testing of Newborns ○ ≥12years: ≥20 breaths per
● Most infants born to people with Covid-19 do not test minute
positive for the virus at birth ● While the diagnosis can be
● The AAP recommends testing healthy infants born to made on clinical grounds,
people infected with SARS CoV-2 at least once before chest imaging (radiograph, CT
hospital discharge and as close to discharge as practical. scan, ultrasound) may assist in
● Newborns with signs and symptoms of Covid-19 should be diagnosis and identity or
tested for SARS CoV-2 immediately exclude pulmonary
● If the mother of the newborn is Covid-19 infected, you can complications.
do swabbing after 24 hours of life, then a repeat at 48 hours
of life. Severe Severe ● Child with clinical signs of
● The testing of newborns is a new recommendation of WHO disease pneumonia pneumonia (cough or difficulty
in breathing) + at least one of
the following:
● Central cyanosis or SpO2 <
C. Testing in Schools 95%; severe respiratory
● Schools may offer diagnostic testing for students and staff distress (e.g. fast breathing,
with symptoms of COVID-19 or who were exposed to grunting, very severe chest
someone with COVID-19 indrawing) general danger
● When COVID-19 community levels are high, schools can sign: inability to breastfeed or
consider implementing screening testing for students and drink, lethargy or
staff, for high-risk activities (for example, close contact unconsciousness, or
sports, band, choir, theater), and at key times in the year, convulsions
for example before/after large events (such as prom, ● Tachypnea (in breaths/min):
tournaments, group travel) and when returning from breaks ○ 3 months old to 12 months old:
(such as, holidays, spring break, at the beginning of the ≥50 breaths per minute
school year). ○ 1 year old to 5 years old: ≥40
● Testing along with COVID-19 vaccination, proper masking breaths per minute
and testing and other mitigation strategies can help prevent ○ 5-12 years: ≥30 breaths per
transmission among students, staff and family members minute
○ ≥12 years: ≥20 breaths per
minute
VII. LABORATORY AND RADIOGRAPHIC
FINDINGS Critical Acute ● Onset: within 1 week of a
● In addition to viral testing, many hospitalized and disease respiratory known clinical insult (i.e.
ambulatory patients will be evaluated with laboratory tests distress pneumonia) or now or
and radiographic studies. Many children will have abnormal syndrome worsening respiratory
vital signs and markers of inflammation when hospitalized (ARDS) symptoms.
for COVID-19. ● Chest imaging: (radiograph,
CT scan, or lung ultrasound):

PREPARED BY: CMED 3EF Page 5 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

bilateral opacities, not fully volume resuscitation, requiring

explained by volume overload, vasopressors to maintain MAP
lobar or lung collapse, or 2 65 mHg and serum lactate
nodules level > 2 mmol/L
● Origin of pulmonary ● Children: any hypotension
infiltrates: Respiratory failure (SBP < 5th percentile or > 2 SD
not fully explained by cardiac below normal for age) or two or
failure or fluid overload. Need three of the following: altered
objective assessment (e.g. mental status; bradycardia or
ECG) to exclude hydrostatic tachycardia (HR < 90 bpm or >
cause of infiltrates / edema if 160 bpm in infants and heart
no risk factor present rate <70 bpm or >150 bpm in
● Oxygenation impairment in children); prolonged capillary
adolescents/adults: refill (> 2 sec) or weak pulse:
○ Mid ARDS: 200 mmHg < fast breathing: matted or cool
PaO2/FiO2 ≤ 300 mmHg skin or petechial or purpuric
(with PEEP or CAP ≥ 5 cm rash, high lactate: reduced
H2O) urine output, hyperthermia or
○ Moderate ARDS: 100 mmHg hypothermia
< PaO2/FiO2 ≤ 200 mmHg
(with PEEP ≥ 5 cm H2O) Acute ● Acute venous
○ Severe ARDS: PaO2/FiO2 thrombosis thromboembolism (ie
≤100mmHg (with PEEP ≥ 5 pulmonary embolism), acute
cm H2O) coronary syndrome acute
● Oxygenation impairment in stroke
children: note Ol and OSI, use
OI when available. If PaO2 not MIS-C ● Preliminary case definition:
available, wean FiO2 to (WHO multisystemic organ
maintain Sp02 ≤ 97% to Classificatio dysfunction children and
calculate OSI or Sp02 /FiO2 n) adolescents 0-19 years of age
ratio: with fever > 3 days AND two of
○ Bilevel (NIV or CPAP) ≥ the following: rash or bilateral
5 cm H2O via full face mask: non-purulent conjunctivitis or
PaO2/FiO2 ≤ 300 mmHg or muco-cutaneous inflammation
SpO2/FiO2 ≤ 264 signs (oral, hands or feet);
○ Mild ARDS (invasively hypotension or shock: features
ventilated): of myocardial dysfunction,
4 ≤ OI < 8 or 5 ≤ OSI <7.5 pericarditis, valvulitis, or
○ Moderate ARDS coronary abnormalities
(invasively ventilated): (including ECHO findings or
8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3 elevated troponin/NT-
○ Severe ARDS proBNP); evidence of
(invasively ventilated): OI ≥ 16 coagulopathy (by PT, PTT,
or OSI ≥ 12.3 elevated D-dimers), açute
gastrointestinal problems
Sepsis ● Adolescents/adults: acute (diarrhea, vomiting, or
life-threatening organ abdominal pain): AND
dysfunction caused by a elevated markers of
dysregulated host response to inflammation such as ESR, C-
suspected or proven infection. reactive protein, or
Signs of organ dysfunction procalcitonin. AND no other
include: altered mental status, obvious microbial cause of
difficult or fast breathing, low inflammation, including
oxygen saturation, reduced bacterial sepsis,
urine output, fast heart rate, staphylococcal or
weak pulse, cold extremities or streptococcal shock
low blood pressure, skin Syndromes. AND evidence of
mottling. laboratory evidence COVID-19 (RT-PCR, antigen
of coagulopathy. test or serology positive), or
thrombocytopenia, acidosis, likely contact with patients with
high lactate, or COVID-19, See scientific brief,
hyperbilirubinemia. 15 May 2020 WHO:
● Children: suspected or proven Multisystemic inflammatory
infection and more than or syndrome in children and
equal to 2 age-based systemic adolescents temporally related
inflammatory response to COVID-19
syndrome (SIRS) criteria, of
which one must be abnormal Table 4. COVID-19 Disease Severity
temperature or white blood cell
count

Septic ● Adolescents/adults:Persiste
shock nt hypertension despite

PREPARED BY: CMED 3EF Page 6 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

VIII. MULTISYSTEM INFLAMMATORY

SYNDROME IN CHILDREN (MIS-C)
● Occurs 2-6 weeks following SARS-CoV-2 infection
● Presents with fever, multisystem organ involvement and
elevated laboratory markers of inflammation
● Often critically ill- more than 50% of patients can require
ICU admission
● May overlap with other conditions kawasaki, toxic shock
syndrome and severe acute covid 19
● If you are presented with a case of high grade fever or
cough differentials can be kawasaki, toxic shock syndrome
and mis-c

IX. MANAGEMENT OF ILLNESS

● Most children with COVID-19 experiences asymptomatic to
mild to moderate infections- that can be managed in
outpatient setting
● Outpatient management- includes supportive care,
consideration of therapeutics in eligible patients at risk for
progression to severe illness and education on measures to
decrease the risk of transmission
● Some children with COVID-19 will experience Severe to
critical illness- will require hospitalization
○ Treatment of hypoxemic respiratory failure,acute
respiratory distress syndrome, septic shock, cardiac
dysfunction, thromboembolic disease, hepatic or renal
dysfunction, CNS disease and exacerbation of
underlying comorbidities
○ Some, but not all, of the medications authorized for the
treatment of severe to critical COVID-19 in adults, have
been authorized for use in children.

X. POST-COVID CONDITIONS (PCS)

● PCs are a wide range of new, returning or ongoing Figure 5. Algorithm on the screening, classification and
symptoms or health conditions people can experience 4 or management of pediatric patients with suspected COVID-19
more weeks after first being infected with the virus that
causes COVID-19
● Symptoms can last for extended periods of time
● Estimates of the proportion of children who experience
COVID-19 and later develop post-COVID conditions range
widely. Rates of post-COVID conditions seem to increase
with age among children and adolescents, and PCCs are
found more often in people who had severe acute COVID-
19 illness than in people with mild or asymptomatic illness
● Commonly reported symptoms in children can include -
headache and fatigue;but many organ systems can be
involved and some children experience multiple symptoms.
● Some studies of post-COVID conditions in children report
that symptoms typically do not persist beyond 12 weeks,
while others have found that symptoms can linger for longer
periods.
● Additional research is needed to learn more about the
symptoms associated with post COVID conditions in the
pediatric population

XI. CONSIDERATIONS FOR ROUTINE

PEDIATRIC CARE DURING THE COVID-19
PANDEMIC
● During 2020-2021, there were significant decline in
outpatient pediatric visits and well child check ups, and
many children have missed recommended screenings and
vaccinations
● CDC recommends the Use the catch up immunization
schedule who are more than 1 month behind on Figure 6. Covid19 Immunization schedule for persons
immunizations and the American Academy of Pediatrics 6 mo of age and older
provides clinical guidance on providing pediatric care
during COVID 19.

PREPARED BY: CMED 3EF Page 7 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 11. Recommended covid vaccine aged 6 mo to 4

yrs.old

Figure 7. Covid 19 Immunization schedule who are not

severely immunocompromised

Figure 12. Recommended covid vaccine age 6 to 11 yrs. old

Figure 8. Covid19 Immunization schedule for persons

6 mo of age and older

Figure 13. Recommended covid vaccine age 12 yrs. old and

older

Figure 9. Recommended covid vaccine age 6 mo

to 4 yrs. old for moderately or severely compromised

Previously Moderna and Pfizer are monovalent unlike now they

are bivalent

Figure 14. Recommended covid vaccine age 5 yrs. old and

older

A. US Centers for Disease Control and Prevention

(CDC) Case Definition for Multisystem
Inflammatory Syndrome in Children (MIS-C)
Figure 10. Recommended covid vaccine age 6 mo ● An individual aged < 21 years presenting with fever,
and older laboratory evidence of inflammation, and evidence of
clinically severe illness requiring hospitalization, with
multisystem (>2) organ involvement (cardiac, renal,
respiratory, hematologic, gastrointestinal, dermatologic or
neurological); AND

PREPARED BY: CMED 3EF Page 8 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN
● No alternative plausible diagnoses; AND
● Positive for current or recent SARS-CoV-2 infection by RT-
PCR, serology, or antigen test; or COVID-19 exposure
within the 4 weeks prior to the onset of symptoms
● Additional comments:
● Some individuals may fulfill full or partial criteria for
Kawasaki disease but should be reported if they meet the
case definition for MIS-C
● Consider MIS-C in any pediatric death with evidence of
SARS-CoV-2 infection
● Several reports have been made about children testing
positive for current or recent infection with SARS-CoV-2,
and presenting with a severe inflammatory syndrome with
Kawasaki disease-like features. This syndrome has since
been named Multisystem Inflammatory Syndrome in
Children (MIS-C).
● Children younger than 2 years old should NOT wear
masks due to risk of suffocation. A mask is also not
recommended in the following situations: if the child has
difficulty breathing when wearing it, if the child has a
cognitive or respiratory impairment giving them a difficult
time tolerating the mask, if the mask is a possible choking
or strangulation hazard, if and if wearing a mask causes the
child to touch their face more frequently.
● Try to find the right size of mask for your child's face and be
sure to adjust it for a secure fit. The regular adult-sized face
mask may be too large for a small child. N95 masks are not
recommended for children and should be reserved for
healthcare workers at increased risk of exposure to COVID-
1.
B. CAREGIVER
● Ideally, assign one person of good health, non-elderly, and
with no underlying comorbidities and immunocompromising
conditions, to avoid undue risk to the caregiver.
● Caregivers should wear a surgical mask that covers their
nose and mouth when in the same room as the patient. DO
NOT touch or handle masks during use. Once wet or dirty
with secretions, remove the mask WITHOUT touching the
front and replace it immediately with a dry mask. DO NOT
reuse masks. Cloth masks do not provide adequate
protection in this setting and should NOT be used.
● Caregivers should use disposable gloves when handling
oral or respiratory secretions, stool or urine. Wash and
disinfect hands after removing gloves.
C. HYGIENE AND SANITATION
● Proper hand washing with soap and water for at least 20
seconds should be performed in these situations:
○ Before and after contact with the child, especially after
handling the child's secretions
○ Before and after preparing the child's food / feeding the
child
○ After assisting the child in using the toilet or diaper-
changing, and after bathing the child
○ If hands are visibly dirty
● Use disposable paper towels or clean cloth towels (with
frequent replacements) to dry hands.
● Avoid direct contact with the child's secretions and stool.
● The toilet should be flushed with the lid down to prevent
droplet splatter and aerosol clouds.
● Clean and disinfect surfaces frequently touched in the room
as well as toilet surfaces using regular household soap or
detergent. Ensure cleaning agents are properly labeled and
stored beyond the child's reach, to prevent accidental
ingestion/poisoning.
D. HOME THERAPIES
● Specific medications against COVID-19 are still under
investigation. Studies are still currently being evaluated,
PREPARED BY: CMED 3EF
SIRMATA 2024
consolidated, and reviewed to ensure that
recommendations are evidence-based.
● Antipyretics such as paracetamol may be given to make the
febrile child more comfortable. The use of ibuprofen has not
been shown to be associated with worse clinical outcomes
compared to paracetamol in one study of adult patients with
COVID-19. However, more studies are needed to ascertain
the safety of ibuprofen in children with COVID-19.
● The Child may be prescribed empiric antibiotic treatment
according to his or her physician's clinical judgment.
Antibiotics should be used rationally based on existing
national guidelines for PCAP and respiratory tract
infections.
● Home nebulization should be avoided unless the child's
physician decides that it is indicated, because the risk of
infection transmission via droplet nuclei or aerosols may
increase during nebulizer treatments. Use a metered dose
inhaler if necessary.
● While getting essential vitamins and minerals such as
Vitamin C, Vitamin D3 and Zinc from supplements may help
bolster the immune system, emphasis must be made on
providing a balanced diet and proper nutrition, as well as
adequate hydration
● Steam inhalation, or the practice of inhalation of water vapor
by leaning over a bowl of boiling water, has been shown to
be ineffective in treating and preventing COVID-19. In
addition, it has been found to be associated with scald
burns.
E. EMOTIONAL AND MENTAL SUPPORT
● If the child can comprehend, parents are encouraged to talk
to the child about their condition in a way they can
understand, giving reassurance that they are being
observed closely at home with the supervision of their
doctor.
● Limit the family's exposure to news coverage, including
social media. Children may misinterpret what they see and
hear, and thus can be frightened about something they do
not understand.
● Continue with the child's regular routine while under
quarantine at home and allow time for learning activities and
simple play if the child feels well enough for it. Observe
limits in screen time as recommended for the child's age.
We only allow gadgets at the age of 2 years and above and
at least 2 hours a day only.
F. MONITORING
● The caregiver should be instructed to record the child's
symptoms and should notify the healthcare provider if the
child's symptoms worsen or if one of the child's contacts
develops symptoms.
● It may be necessary to bring the child to the nearest health
care facility for proper assessment if symptoms worsen or if
no improvement is seen in 2-3 days at home.
G. PATIENTS WITH MODERATE, SEVERE OR
CRITICAL SYMPTOMS
● All patients with moderate, severe or critical symptoms
should be admitted, would be assumed as having COVID-
19 and should be tested.
● Alternatively, if the facility is not equipped to handle COVID-
19 patients, referral to a COVID-19 referral center must be
done.
H. IN-PATIENT MANAGEMENT
● The child should be admitted in the hospital and placed in
an isolation room or in a dedicated COVID-19 ward/floor, as
soon as possible.
● A dedicated healthcare worker should be in full Personal
Protecti
Page 9 of 27
 PEDIATRICS (019) COVID-19 IN CHILDREN
● Equipment (cap, N95 mask, goggles, face shield, full
impermeable gown, gloves, and shoe covers) when
handling the patient. Proper donning and doffing of PPEs
and infection control measures should be observed at all
times.
● Specimen collection must be performed by a
knowledgeable medical worker. Ensure that assistance is
available as the child may be uncooperative during the
procedure. Collect a nasopharyngeal swab (NPS) and / or
an oropharyngeal swab (OPS), and if possible, a lower
respiratory tract specimen. Samples must be sent to the
Research Institute for Tropical Medicine (RTM) or to a DOH-
accredited laboratory through the proper channels. Case
investigation forms (CIF) must be accurately filled out for
proper documentation.
● The WHO recommends standard, contact, and droplet
precautions with eye and face protection, with the addition
of airborne precautions as needed during aerosol-
generating procedures.
I. DIAGNOSTICS
● Molecular Based Assays
○ Nucleic acid amplification testing using the reverse
transcriptase polymerase chain reaction (RT-PCR) is
the preferred method for diagnosing SARS-CoV-2
infection.
○ Appropriate specimens include samples collected from
the upper (pharyngeal swabs, nasal swabs,
nasopharyngeal secretions) and/or lower airways
(sputum, airway secretions, bronchoalveolar lavage
fluid)
○ The Department of Health advises the collection of both
nasopharyngeal and oropharyngeal specimens.
○ For patients for whom it is clinically indicated (e.g.
those receiving invasive mechanical ventilation), a
lower respiratory tract aspirate or bronchoalveolar
lavage sample should be collected and tested as a
lower respiratory tract specimen.
○ Among the upper respiratory tract specimens,
nasopharyngeal and nasal swabs have the highest
sensitivity.
○ In a study by Wang et al. of 1,078 specimens collected
from 205 adult patients with confirmed COVID-19
infection, RT-PCR positivity was highest in
bronchoalveolar lavage specimens (93%), followed by
sputum (72%), nasal swab (63%), pharyngeal swab
(32%), feces (29%) and blood (1%).
○ None of the urine specimens tested positive.
○ A similar study by Yuan et al. of 212 children comparing
the viral load in throat and anal swabs has shown that
78 of 212 patients were confirmed with SARS-CoV-2
infection according to the positive results obtained from
either throat or anal swabs.
○ Of the 78 patients, 17 were positive on anal swabs, 37
were positive on throat swabs, and 24 were positive on
both.
○ The RT-PCR positivity rate was 78.2% for throat swabs
vs 52.6% for anal swabs.
○ SARS-CoV-2 preferentially proliferates in type I|
alveolar cells (AT2) and peak of viral shedding appear
3 to 5 days after the onset of disease. Median duration
of viral RNA detection was 20 days and the longest
observed duration of viral shedding was 37 days in
survivors.
○ Appropriate respiratory specimens should be collected
as soon as possible once a suspect COVID-19 case is
identified, regardless of the time of symptom onset.
○ A positive test for SARS-CoV-2 confirms the diagnosis
of COVID-19.
○ If initial testing is negative but the suspicion for COVID-
19 remains, resampling and testing from multiple
respiratory tract sites is recommended.
PREPARED BY: CMED 3EF
SIRMATA 2024
○ Results of RT-PCR assays may be affected by the
adequacy of sample, collection, handling and transport
of specimen, and timing of sample collection in relation
to symptom onset.
○ Kucirka et al. reported that on day 1 from exposure, the
sensitivity of RT-PCR is 0%. Before symptom onset (on
the average, day 4 from exposure), the sensitivity is at
33%.
○ On the day of symptom onset (typically day 5 from
exposure), the sensitivity is at 62%.
○ This further increases to 80% on the 3rd day of
symptoms (or average of day 8 from exposure).
○ Sensitivity decreases to 34% on day 21 of exposure.
The sensitivity is highest 3 days after symptom onset
on average, or 8 days after exposure.
● Serologic test
○ Specific antibodies (IgM and IgG) are produced after
SARS-CoV-2 infection and can be detected by a variety
of methods from the blood, e.g. lateral flow
immunochromatographic assay (LFIA), enzyme linked
immunosorbent assay (ELISA), chemiluminescence
immunoassay (CLIA), etc.
○ Determining unique viral protein targets to reduce
crossreactivity to other coronaviruses is a challenge
and can affect test sensitivity and specificity.
○ According to a Cochrane systematic review by Deeks
et al., pooled results for IgG, IgM, IgA, total antibodies
and IgG/IgM all showed low sensitivity during the first
week from onset of symptoms (less than 30.1%), rising
in the second week, and reaching their highest values
in the third week.
○ The combination of a gG/IgM had a sensitivity of 30.1%
at day 1 to day 7 from the time of exposure, 72.2% at 8
to 14 days, 91.4% at 15 to 21 days, and 96% at 21 to
35 days.
○ There are insufficient studies to estimate sensitivity of
tests beyond 35 days post-symptom onset.
○ A systematic review by Bastos et al. compared the
diagnostic accuracy of different methods of serological
tests (ELISA, LFIA, and CLIA). The pooled sensitivity
of ELISA was 84.3%, of LFIA was 66%, and of CLIA
was 97.8%
○ However, the study also reported a high or unclear risk
of bias in 98% of the studies, and results were not
stratified by the timing of sample collection in relation
to symptom onset in 67% of the studies.
○ At present, it is still unknown whether antibodies persist
following infection and whether the presence of
antibodies confers protective immunity against future
infection.
● Ancillary Laboratory Tests
○ The possible results seen in patients with COVID-19
are based on recently published studies. Other tests
may be ordered depending on the child's presentation
and upon the physician's discretion.
○ The WBC count is generally normal, however,
lymphopenia has been frequently reported, with a
median absolute lymphocyte count (ALC) of 1,201
cells/uL (normal ALC 1,500-3,000 cells/uL).
○ Platelet count may be normal. However,
thrombocytopenia has been reported in several case
reports of COVID-19 patients presenting with fever,
initially assessed to have dengue fever based on
positive serology. The presentation of fever and
thrombocytopenia is important to recognize in the local
setting where dengue fever is common. - If you’re given
a case of high grade fever with cough differentials does
not only include kawasaki’s disease, toxic shock
syndrome you also think of the possibility of dengue
case
○ Inflammatory markers
○ Among the inflammatory markers investigated,
procalcitonin, D-dimer and interleukin-6 were found to
be elevated.
Page 10 of 27
 PEDIATRICS (019) COVID-19 IN CHILDREN
○ Increased procalcitonin levels may be seen in patients
with severe COVID-19 without bacterial co-infection;
however, a rapid rise or significantly elevated
procalcitonin may also indicate secondary bacterial
infection.
○ Arterial Blood Gas (ABG) or pulse oximetry
○ Obtaining an arterial blood gas analysis or performing
pulse oximetry can be done to assess the severity of
hypoxemia in patients with pneumonia.
○ An oxygen saturation at room air of < 95% may indicate
pneumonia; a value < 90% may indicate severe
pneumonia.
○ Other tests to determine alternative etiology or
secondary infection
○ Whenever possible, it is advised to determine an
alternative etiology for the patient's symptoms.
○ However, co-infections with COVID-19 have been
documented, and tests that are positive for other
bacterial or viral pathogens do not rule out COVID-19.
○ ConSider the following diagnostic tests, depending on
the patient's presenting signs and symptoms;
○ Bacterial and fungal cultures (blood, stool, urine and
other appropriate specimens) to test for bacterial or
fungal infection, ideally collected before start of
antimicrobial or antifungal therapy
○ Dengue NS1 and dengue serologic tests (IgM, lgG)
must be requested for patients who present with
symptoms of dengue. Take note, however, that
symptoms of dengue and COVID-19 overlap, and that
there have been reported cases of confirmed COVID-
19 patients with false positive dengue NS1 and
serology
○ Rapid antigen detection tests for specific bacterial or
viral pathogens
○ Multiple respiratory or gastrointestinal panel tests
J. IMAGING STUDIES
• Chest x-ray
o Chest x-ray is the recommended first line imaging
modality in children suspected to have COVID-19
presenting with respiratory symptoms.
o However, this modality has limited sensitivity and
specificity, hence, a negative chest x-ray does not
exclude pulmonary involvement in patients with
laboratory-confirmed COVID-19, nor does it indicate
absence of infection in cases of suspected COVID-19
not yet confirmed by RT-PCR
o findings include ground glass opacities and
consolidations
• Chest CT scan
o Chest CT scan is not recommended as the initial
diagnostic test in pediatric patients suspected to have
COVID-19.
o Chest CT scan findings of COVID-19 in the pediatric
population are not pathognomonic but may be
suggestive of the diagnosis in the appropriate clinical
setting.
o It may be considered in patients with a worsening
clinical course who are not responding appropriately to
therapy, or to further investigate a specific pulmonary
condition.
• Chest ultrasound
o Chest ultrasound has been used as an alternative to
chest x-ray and chest CT scan in the diagnosis of
pneumonia in COVID-19 patients due to its ease of use
at point-of-care, absence of radiation exposure, and
lower cost than CT scan. Chest CT scans performed in
COVID-19 patients have been shown to have a strong
correlation with chest ultrasound.
PREPARED BY: CMED 3EF
SIRMATA 2024
K. ULTRASONOGRAPHIC FEATURES SEEN IN COVID
19 PNEUMONIA
● Thickening of the pleural line with pleural line irregularity
● B lines in a variety of patterns including focal, multi-focal,
and confluent
● Consolidations in a variety of patterns including multifocal
small, nontranslobar, and translobar with occasional mobile
air bronchograms
● Appearance of A lines during recovery phase
● Pleural effusions are uncommon
● The use of investigational drugs should be discussed with
the parents or legal guardian of the child, carefully
explaining the potential clinical benefits and potential
adverse reactions of these investigational drugs.
● A signed informed consent form should be obtained by the
clinician - remember also to explain to the patient the
contents of the informed consent and make sure they
understand it
XII. REFERENCES
● https://www.cdc.gov/coronavirus/2019-
ncov/hcp/pediatric-hcp.html
XIII. TEST YOUR KNOWLEDGE
1. Which underlying condition had the highest prevalence
among the cohort in the study?
A. immunosuppression
B. Respiratory conditions
C. Cardiovascular conditions
D. Complex congenital malformations
2. Which of the following procedures has the potential to
contribute to airborne transmission of COVID-19?
A. Chest physiotherapy
B. Nebulizer treatment
C. Nasogastric tube placement
D. Endotracheal intubation and extubation
3. In which of the following situations can airborne transmission
of COVID-19 occur?
A. Touching contaminated objects and surfaces
B. Inhalation of infected respiratory droplets
C. Non-invasive positive pressure ventilation (NIPPV)
D. Contact of mucosal surfaces of the eyes, nose, and mouth
4. Which symptom is commonly associated with COVID-19
infection?
A. Sore throat
B. Rhinorrhea
C. Fatigue
D. Gastrointestinal symptoms
5. A patient presents to the clinic with the following symptoms:
fever and cough. They also complain of headaches and fatigue.
The physician suspects a possible COVID-19 infection based on
the clinical presentation.
What is the recommended action for the physician in this
situation?
A. Request a Rapid Antigen Test (RAT) for confirmation
B. Prescribe antibiotics for the symptoms
C. Advise the patient to rest and monitor their symptoms at home
D. Refer the patient to a specialist for further evaluation
6. True or False Chest CT scan is recommended as the initial
diagnostic test in pediatric patients suspected to have COVID-
19.
7. An individual aged > 21 years presenting with fever,
laboratory evidence of inflammation, and evidence of clinically
severe illness requiring hospitalization, with multisystem (>2)
Page 11 of 27
 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

organ involvement (cardiac, renal, respiratory, hematologic,

gastrointestinal, dermatologic or neurological)

8. MIS-C occurs _____ weeks following SARS-CoV-2 infection

A. 3-5 weeks
B. 4-7 weeks
C. 2-6 weeks
D. 1-3 weeks

9. Children younger than ____ years old should NOT wear

masks due to risk of suffocation.
A. 4 years old
B. 6 years old
C. 2 years old
D. 3 years old

10. Onset: within 1 week of a known clinical insult (i.e.

pneumonia) or now or worsening respiratory symptoms.
A. ARDS
B. Critical Disease
C. Moderate Disease
D. A and B

Answers: A D C C A False False C C D

PREPARED BY: CMED 3EF Page 12 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

XIV. APPENDIX

Figure 1. Salvacion COVID-19 profile

PREPARED BY: CMED 3EF Page 13 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 2. Salvacion COVID-19 manifestations and management

Figure 3. Classification Scheme of Coronavirus

PREPARED BY: CMED 3EF Page 14 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Table 1. SARS COV-2 LIST OF VARIANTS

Table 2. Clinical Symptoms of COVID-19 in children

PREPARED BY: CMED 3EF Page 15 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Table 3. Theories regarding Susceptibility of Children to COVID-19

PREPARED BY: CMED 3EF Page 16 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 4. Diagnostic Testing for Covid-19

PREPARED BY: CMED 3EF Page 17 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 5. Algorithm on the screening, classification and management of pediatric patients with suspected COVID-19

PREPARED BY: CMED 3EF Page 18 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 6. Covid19 Immunization schedule for persons 6 mo of age and older

PREPARED BY: CMED 3EF Page 19 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 8. Covid19 Immunization schedule for persons 6 mo of age and older

Figure 7. Covid 19 Immunization schedule who are not severely immunocompromised

PREPARED BY: CMED 3EF Page 20 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 9. Recommended covid vaccine age 6 mo to 4 yrs. old

Figure 10. Recommended covid vaccine without immunocompromised age 6 mo to 4 yrs. old

PREPARED BY: CMED 3EF Page 21 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 11. Recommended covid vaccine age 6 to 11 yrs. old

PREPARED BY: CMED 3EF Page 22 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 12. Recommended covid vaccine age 5 yrs. old and older

Figure 13. Recommended covid vaccine age 12 yrs. old and older

PREPARED BY: CMED 3EF Page 23 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 14. Recommended therapy for severe and Critical Covid 19

PREPARED BY: CMED 3EF Page 24 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 15. Experimental Therapy for Mild and Moderate Covid 19

Figure 16. Experimental Therapy for Severe and Critical Covid 19

Figure 17. Anticoagulation for Covid 19

PREPARED BY: CMED 3EF Page 25 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

Figure 18. Anticoagulation for Covid 19

Figure 19. Anticoagulation for Covid 19

PREPARED BY: CMED 3EF Page 26 of 27

 PEDIATRICS (019) COVID-19 IN CHILDREN SIRMATA 2024

PREPARED BY: CMED 3EF Page 27 of 27