A protocol for managing children with coronavirus disease has been issued by the Union Ministry of health and family welfare, with separate guidelines for those who are asymptomatic and those with mild, moderate and severe illness. Asymptomatic children do not require any treatment, except monitoring for development of Covid-19 symptoms and subsequent treatment according to assessed severity, it says.
It further stated on Thursday, “Majority of children with covid infection may be asymptomatic or mildly symptomatic. Common symptoms include fever, cough, breathlessness or shortness of breath, fatigue, myalgia, rhinorrhea, sore throat, diarrhea, loss of smell, loss of taste etc. Few children may present with gastrointestinal symptoms and atypical symptoms. A new syndrome with name of multi system inflammatory syndrome has been described in children. Such cases are characterized by: unremitting fever > 38oC, epidemiological linkage with SARS CoV-2 and clinical features suggestive of Multi System Inflammatory Syndrome.”
The health ministry said children with Covid 19 infection may be asymptomatic, mildly symptomatic, moderately sick or severe illness. “Asymptomatic children are usually identified while screening, if family members are identified. Such children do not require any treatment except monitoring for development of symptoms and subsequent treatment according to assessed severity,” it said.
The ministry added, mild disease in children may present with sore throat, rhinorrhea or runny nose, cough with no breathing difficulty and a few children may have gastrointestinal symptoms. Such children do not need any kind of investigation and can be managed at home with home isolation and symptomatic treatment, the guidelines state.
“Children with underlying comorbid condition including: congenital heart disease, chronic lung diseases, chronic organ dysfunction, Obesity (BMI> 2SD) may also be managed at home, if they have features of mild disease and there is easy access to health facility in case of any deterioration. In case there is lack of proper arrangement to manage these children at home/ access to health facility is difficult, such children may be admitted,” it said.
How should children with mild illness in home isolation be treated?
They said, the guidelines recommend throat soothing agents like warm saline gargles for cough and oral fluids to maintain hydration and a nutritious diet. In case for fever the treating doctor prescribed paracetamol (10-15 mg/kg/dose), which may be repeated every four to six hours.
Antibiotics are “not indicated” for treating mild illness in children, they said. “There is no role of Hydroxychloroquine, Favipiravir, Ivermectin, lopinavir/ritonavir, Remdesivir, Umifenovir, Immunomodulators including Tocilizumab, Interferon B 1 a, Convalescent plasma infusion or dexamethasone,” it also said.
How is moderate disease in children categorised?
A child with Covid-19 will be categorised as having the moderate disease (oxygen saturations above 90%) if they have the following:
Rapid respiration benchmarks based on the age of the child:
- Less than 2 months old: respiratory rate >60/ min
- Between 2-12 months: respiratory rate >50/min
- Between 1-5 years: respiratory rate >40/min
- Over 5 years: respiratory rate >30/min.
“Children with moderate Covid -19 disease may be suffering from pneumonia which may not be clinically apparent,” the protocol states. It says no lab tests are required routinely, unless indicated by associated co-morbid conditions.
What is the treatment recommended for moderate disease in children?
The protocol recommends that children with moderate Covid-19 disease should be admitted in a dedicated Covid health centre or secondary-level healthcare facility and monitored for clinical progress.
It recommends that fluid and electrolyte balance should be maintained. “Encourage oral feeds (breast feeds in infants); if oral intake is poor, intravenous fluid therapy should be initiated,” it recommends.
If there is evidence/strong suspicion of bacterial infection Amoxycillin to be administered. For oxygen saturation below 94%, oxygen supplementation is required and children with moderate Covid-19 disease should be administered with paracetamol 10-15 mg/kg/dose, which may be repeated every four to six hours for temperature > 38°C or 100.4°F. ”
In rapidly progressive disease Corticosteriods may be administered.
It added, “The protocol says steroids is not required in all children with moderate illness, specifically during the first few days of illness. Supportive care for comorbid conditions, if any.”
How does the protocol categorise severe disease in children?
Children with oxygen saturation level less than 90% have severe degree of Covid-19 infection. Such children may have severe pneumonia, Acute Respiratory Distress Syndrome (ARDS), septic shock, Multi-Organ Dysfunction Syndrome (MODS), or pneumonia with cyanosis or bluish discoloration caused by deoxygenation. Clinically, such children may present with grunting, severe retraction of chest, lethargy, seizure, the protocol states.