Pediatric Respirology and Critical Care Medicine

REVIEW ARTICLE
Year
: 2020  |  Volume : 4  |  Issue : 2  |  Page : 25--27

Treatment of mild to moderate COVID-19 in children


Sushil Kumar Kabra 
 Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Sushil Kumar Kabra
Department of Pediatrics, All India Institute of Medical Sciences, New Delhi - 110 029
India

Abstract

Children as such have less infection and less severe covid 19 illness. Majority will be asymptomatic or mildly symptomatic. Symptoms are nonspecific and suspect in children presenting with influenza-like illness (ILI) or children presenting with respiratory difficulty. Children with definite contact with COVID-positive patients or those who had severe illness (irrespective of COVID status) in the past 2 weeks should be subjected to test. The rest of the children may be tested if any of the following are present: 1. The presence of high-risk factor in child such as immunocompromised condition (long-term steroids, cancer chemotherapy, biological agents, and primary or secondary immune deficiency) or chronic illnesses including chronic respiratory illnesses 2. Any person in family who is at risk of developing serious illness (elderly, immunocompromised, diabetic, hypertensive, etc.,). Majority of mild to moderate illness can be managed at home with symptomatic treatment ensuring monitoring for worsening of symptoms. There is no proven benefit of antibiotics, antiviral agents, steroids, hydroxychloroquine or other anti-inflammatory agents.



How to cite this article:
Kabra SK. Treatment of mild to moderate COVID-19 in children.Pediatr Respirol Crit Care Med 2020;4:25-27


How to cite this URL:
Kabra SK. Treatment of mild to moderate COVID-19 in children. Pediatr Respirol Crit Care Med [serial online] 2020 [cited 2021 Apr 16 ];4:25-27
Available from: https://www.prccm.org/text.asp?2020/4/2/25/311047


Full Text



COVID-19 pandemic is ongoing since December 2019, it is unclear, what will be its course. However, we can definitely say that COVID-19 infection is going to stay with us for months to year.[1] As of now, most countries have developed separate COVID care teams for testing and managing different severity of cases. Once the pandemic gets flattened, sporadic cases or localized outbreaks in different geographic regions will continue to occur. Children as such have less infection and less severe illness. Majority will be asymptomatic or mildly symptomatic. Majority can be treated with home isolation and supportive care.[2] Therefore, pediatricians and general practitioners will play an important role in the identification and management of such patients.

 When to Suspect



COVID-19 is no more a restricted disease to particular continent. As the symptoms are similar to any viral respiratory tract infection, it is very difficult to identify COVID infection on the basis of clinical symptoms alone. Therefore, keeping a high index of suspicion is important. It may not be exaggeration to suggest that all children presenting with influenza-like illness (ILI) like symptoms may have COVID-19 infection. With time when panic goes down and we are more confident, approach will change. Most children with mild-to-moderate illness can be managed at home with precautions for high-risk groups.

 Approach to Children Presenting with Influenza-Like Illness



Any child presenting with ILI for <10 days duration may be assessed for likelihood of COVID infection and severity of illness.

Likelihood of COVID

Children who come from a family or definite contact with COVID-infected adults are considered to have COVID infection. As the infection can be transmitted by individuals with asymptomatic infection or presymptomatic (still not developed symptoms), it is very difficult to identify contact with COVID infection.

 Whom to Test



It is difficult to decide whom to test and isolate. All children with definite contact with COVID-positive patients or those who had severe illness (irrespective of COVID status) in the past 2 weeks should be subjected to test. The rest of the children may be tested if any of the following are present:

The presence of high-risk factor in child such as immunocompromised condition (long-term steroids, cancer chemotherapy, biological agents, and primary or secondary immune deficiency) or chronic illnesses including chronic respiratory illnessesAny person in family who is at risk of developing serious illness (elderly, immunocompromised, diabetic, hypertensive, etc.,).

If none of these are present, child may be treated with home isolation unless has moderate or severe illness.

 Pathways to Follow for Children with Influenza-Like Symptoms



All children presenting with ILI should be assessed by asking mother about, oral intake, difficulty in respiration. Child should be examined for the respiratory rate counting for full minutes, look for lower chest indrawing, and check oxygen saturation. Based on the above observations, may be classified as mild/moderate or severe illness.[3]

 Management of Mild and Moderate Illness without Hypoxia



These children have no respiratory difficulty, or mild lower chest in-drawing, feeding well, have SpO2 >92% and feasibility of monitoring home can be managed at home isolation facility. For home isolation, need to assess feasibility (availability of room, with wash room, no adult with high risk, possibility of monitoring/teleconsultation at home, and taking child to health-care facility immediately to health-care facility). If feasible, may be treated at home. If this is not feasible, then the child should be managed in COVID care facility (if available).

Antibiotics

No role routinely.

Antiviral agents

There is no role of antiviral agents such as lopenavir-Retinovir and Interferon alfa). There are no studies of benefits of remdisavir in mild-to-moderate illness in children. Studies in adults suggest some beneficial role in moderate-to-severe illness [Table 1].{Table 1}

Dexamethasone

Studies in adults suggest the survival benefit in severe illness, but no significant improvement in mild illness. There are no randomized controlled trials in children.

Other medications

Hydroxychloroquine was advocated in the beginning of pandemic, now randomized controlled trials have shown that there is no role of hydroxychloroquine. In some patients with severe illness secondary to cytokine storm, anti-interleukin 6 Tocilizumab and human plasma infusion has shown some improvement. However, as of now, there is no conclusive evidence of beneficial roles of these medications in mild-to-moderate illness in children.

 Supportive Care



Control of fever using paracetamol (10–15 mg/kg/dose SOS/q 4–6 hourly if required). Regarding the use of nonsteroidal anti-inflammatory drugs (NSAIDs), indirect evidence suggests no evidence of severe adverse effect in viral respiratory infection.[4] There is no direct evidence for adverse effect of NSAIDs in COVID-19 infection. Therefore, may be used if indicated.

Ensure adequate hydration by asking parents to give the plenty of liquids to child.

 Monitoring at Home



Children being managed in home isolation require good monitoring to identify deterioration early and seek medical advice. Monitoring consist of observing for the development of respiratory difficulty (rapid respiration and chest indrawing), reduced feeding, development of lethargy, dull sensorium, seizures, cold extremities, reduced urine output, and if feasible fall in oxygen saturation of <92%. It is desirable that mother or any other person in family is trained in monitoring and keeping records at least twice a day. It is also desirable that doctor contacts the family at least once a day to family telephonically or by video to assess the status till child is afebrile and complete recovery.

When to take the child to health care facility

If child develops any of the above parameters, family should contact treating doctor and act as per the advice of doctor. If not able to contact doctor should take the child to nearest health-care facility for assessment.

 Precautions for Parents



The parent/caregiver should take the necessary precautions and use appropriate PPE including a mask. Frequent washing of hands or use of sanitizer, frequent washing, or cleaning of toys of child. Keeping child isolated from other members of household. If any other member of household develops ILI symptoms, to get their test for COVID-19 infection.

 Duration of Isolation



Child should be afebrile for 72 h and at least 7 d after symptom resolution OR negative samples (if done earlier). Virus shedding can last up to 4 weeks in symptomatic children and infection control measures such as wearing mask and stringent hand hygiene should be practised. Repeat test is indicated only in children who have underlying illness.

Children with moderate illness with hypoxia and severe illness

These children need hospitalization and appropriate supportive care.

A new manifestation of COVID 19 infection

A new syndrome called “Multisystem inflammatory syndrome temporally related to COVID-19” has been described recently. Children may present with fever >3 days, rash/nonpurulent conjunctivitis/mucocutaneous signs, hypotension, myocardial dysfunction, coagulopathy, acute GI problems, elevated markers of inflammation, evidence of COVID-19 (antigen or serology)/likely contact with positive patient, and no obvious bacterial cause. These children may need treatment in pediatric intensive care unit, supportive care such as systemic steroids with or without IV IgG infusion.[5]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Lodha R, Kabra SK. COVID-19 Pandemic: The Way Forward. Indian J Pediatr 2020;87:676-9.
2Sankar J, Dhochak N, Kabra SK, Lodha R. COVID-19 in children: Clinical approach and management. Indian J Pediatr 2020;87:433-42.
3World Health Organization. Clinical management of COVID-19: Interim guidance. World Health Organization 2020. World Health Organization; 2020. p. 5.
4The use of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with COVID-19. Geneva: World Health Organization; 2020. Available from: https://www.who.int/news-room/commentaries/detail/the-use-of-non-steroidal-anti-inflammatory-drugs-(nsaids)-in-patients-with-covid-19, 20). [Last accessed on 2020 May 20].
5Nakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. Multi-system inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection: Review of clinical presentation, hypothetical pathogenesis, and proposed management. Children (Basel) 2020;7:69.