Disposition
Admission criteria
Admission decisions consider a combination of clinical presentation, supportive care requirement, underlying medical comorbidity, and caregiver's ability to provide home care
Admission is recommended for children with moderate COVID-19 symptoms (eg, clinical or radiographic evidence of lower airway disease) for supportive care and observation r4
Admit all children with severe COVID-19 for expedient management, preferably at a regional center with critical care and extracorporeal membrane oxygenation capability r4
Febrile neonates (most younger than 28 days) require admission for further diagnosis, management, and monitoring r45
Consider admitting children with mild disease and significant underlying comorbidity for management and close monitoring for clinical deterioration r23
Criteria for ICU admission
- General ICU admission criteria apply: septic shock, cardiogenic shock, acute respiratory distress syndrome, need for advanced airway or ventilatory support, or multiple organ failure r4
- Admit children with progressing severe disease and critical COVID-19 illness to pediatric ICU for expedient management, preferably at a regional center with extracorporeal membrane oxygenation capability r4
Recommendations for specialist referral
- COVID-19 is a nationally notifiable disease; manage in consultation with public health authorities
- Reporting of cases to the CDC is supported by routine case notification through the National Notifiable Diseases Surveillance System and resources provided through the CDC COVID-19 Response Team r46
- Consult infectious disease specialist to coordinate diagnosis and management with public health authorities
- Manage complications and severe or critical disease in consultation with appropriate specialty service (eg, pediatric pulmonologist, pediatric intensive care specialist)
Treatment Options
Implement early and maintain strict transmission-based precautions for any patient with possible SARS-CoV-2 infection
- Minimum health care facility transmission-based precautions include contact, respiratory droplet, and airborne precautions during aerosol-generating procedures r32
- Use of gown, gloves, and N95 respirator with eye protection (goggles or face shield) or air purifying respirator that provides eye protection is standard
Supportive care is the mainstay of management for the overwhelming majority of pediatric patients; most children can be managed safely in the home environment r47
General supportive measures may include:
- Basic supportive care measures
- Caregiver education
- Provide anticipatory guidance for home care and resources about emergency warning signs for worsening COVID-19 manifestations
- Provide recommended isolation measures to minimize secondary spread of COVID-19 r13
- Educate about avoidance of sports and physical activity until cleared by physician r48
- Antipyretics and OTC pain relievers
- Ibuprofen or acetaminophen is recommended for symptomatic care r4r49
- Encourage fluids and nutrition as tolerated by mouth
- Resources for parents are readily available from various medical organizations (eg, American Academy of Pediatrics,r50CDC,r51r52r36WHOr53) to help guide home care for children with COVID-19
- Advanced supportive care measures
- Treat dehydration and provide hydration support in standard fashion
- Use parenteral hydration via IV or enteral hydration via nasogastric tube if patient is unable to tolerate fluids by mouth r4
- Advantage of enteral route is ability to provide added nutritional support
- Parenteral hydration is preferred for patients with poor or declining clinical status
- Goal is euvolemic state; aggressive fluid management may impair alveolar oxygen exchange
- Provide advanced nutritional support if needed r23
- Start oxygen when indicated for persistent oxygen saturation less than 92% r54
- Target oxygen saturation is 92% to 96% r6
- Provide airway and respiratory support when clinically indicated
- Perform a 30- to 90-minute trial of noninvasive ventilatory support (CPAP, BPAP, high-flow nasal canula) before advancing to invasive mechanical ventilation, when clinical status allows r39
- Optimize first-pass intubation success by having most experienced provider perform procedure r4
Administer specific antivirals (eg, oseltamivir for influenza) and appropriate antibiotics (eg, empiric antibiotics for sepsis) in accordance with disease severity, acquisition site (community or hospital), epidemiologic risk factors, and local antimicrobial susceptibility patterns r14
Follow evidence-based recommendations for septic shock and sepsis-related organ dysfunction as outlined in the Surviving Sepsis Campaign guidelines r55
Follow evidence-based recommendations for pediatric acute respiratory distress syndrome as outlined in Pediatric Acute Lung Injury Consensus Conference recommendations r56
General guidance regarding use of COVID-19–specific treatments in children:
- The older the child and the more severe the illness: consider using recommended adult COVID-19 treatment guidelines r6d12
- Enroll children in clinical trialsr57 and multicenter pragmatic trials whenever possible r6
- Most COVID-19 treatment trials to date have not included pediatric patients; therefore, pharmacotherapeutic treatments largely are based on expert opinion or reflect data obtained from adult series r58
- Frequently updated resources available to aid in most current treatment recommendations and guidance include:
- NIH COVID-19 Treatment Guidelines r6
- American Academy of Pediatrics COVID-19 Interim Guidance r59
- Infectious Diseases Society of America Pediatric COVID-19 Clinical Guidance r58
- Infectious Diseases Society of America Therapeutics and Interventions resources and Guidelines on the Treatment and Management of Patients With COVID-19 r60r61
- WHO COVID-19 Clinical Management: Living Guidance r14
COVID-19 treatment-specific therapies and pharmacotherapeutic options:
- No drugs are specifically approved by FDA for treatment of COVID-19 in children younger than 12 years r13
- Nirmatrelvir-ritonavir r62
- Protease inhibitor that prevents viral replication with antiviral activity against coronaviruses
- First choice pharmacotherapeutic indicated for treatment of patients aged 12 years and older and weighing 40 kg or more with mild to moderate COVID-19 who are at high risk of progression to severe disease and do not require hospitalization for COVID-19
- Initiate oral dosing as soon as possible and within 5 days of symptom onset
- Ritonavir-boosted nirmatrelvir has significant and complex drug interactions; carefully review medication profile (including OTC and herbal supplements) before initiation
- Liverpool COVID-19 drug interaction website,r63ritonavir-boosted nirmatrelvir fact sheet,r64 and NIH guidelinesr62 can help identify potential drug interactions
- Remdesivir
- Nucleotide analogue prodrug that inhibits viral RNA polymerases
- Most beneficial when started early in the course of illness (fewer than 7 days after first symptom) in patients meeting criteria for treatment r65
- FDA approved to treat COVID-19 in hospitalized adult and pediatric patients aged 12 years and older and weighing 40 kg or more r6
- Available through FDA emergency use authorization or expanded access (ie, compassionate use) programs for hospitalized children younger than 12 years weighing from 3.5 kg to less than 40 kg r66
- Studies are ongoing to evaluate safety and efficacy in children r13
- FDA recommended third choice treatment (first choice, nirmatrelvir-ritonavir; second choice, sotrovimab) for high-risk nonhospitalized children aged 12 years and older weighing 40 kg or more with mild to moderate COVID-19 r65
- Recommended for the following hospitalized pediatric patients with COVID-19: r6
- Children 12 years or older with risk factors for severe disease and an emergent or increasing supplemental oxygen requirement
- Children 16 years or older with an emergent or increasing supplemental oxygen requirement regardless of risk factors for severe disease
- Consider using (in consultation with infectious disease specialist) for the following hospitalized pediatric patients with COVID-19 (recommended) r6
- Children of any age with emergent or increasing supplemental oxygen requirement
- Additional multicenter interim guidance recommendations for use of antivirals for children with severe or critical disease, as established by a panel of pediatric infectious disease physicians and pharmacists, are outlined in a report in the Journal of the Pediatric Infectious Diseases Societyr47
- Dexamethasone
- Efficacy and safety data in children are limited; treatment in context of enrollment in a clinical trial is ideal r67
- Recommended for select hospitalized pediatric patients with severe or critical COVID-19 who require any of the following: r6
- High-flow oxygen
- Noninvasive ventilation or invasive mechanical ventilation
- Extracorporeal membrane oxygenation
- Use has not been studied in patients with severe immunocompromise; given the theoretical potential for harm, consider—on a case-by-case basis—using to treat severe COVID-19 in patients with significant immunocompromise r6
- Alternative glucocorticoids (eg, prednisone, methylprednisolone, hydrocortisone) may be substituted if dexamethasone is not available r6
- Anti–SARS-CoV-2 monoclonal antibody products
- Neutralizing IgG monoclonal antibodies that bind spike protein of SARS-CoV-2 and prevent attachment of virus to human ACE-2 receptors
- Products with emergency use authorizations for treatment in children with mild to moderate COVID-19 at high risk for severe disease have included bamlanivimab plus etesevimab (children weighing more than 1 kg), casirivimab plus imdevimab (children 12 and older and 40 kg or greater), sotrovimab (children 12 years and older and 40 kg or greater), and bebtelovimab (children 12 and older and 40 kg or greater) r27r68
- Sotrovimab and bebtelovimab are thought to be the only monoclonal antibody formulations with efficacy against Omicron variant; the FDA's emergency use authorizations for the others have been emended to specify variant susceptibility, effectively suspending their use in the United States r65r68
- Recommended to consider (in consultation with infectious disease specialist) on a case-by-case basis for children who fulfill emergency use authorization criteria for high risk of progression to severe disease or hospitalization r27
- May be used for children hospitalized for other indications who coincidentally develop symptomatic infection during hospitalization r28
- Detailed description of risk factors for severe COVID-19 disease (eg, obesity, medical complexity with respiratory technology dependence, specific severe immunocompromising conditions) are available r28
- Treatment in the context of enrollment in clinical trial is ideal r67
- Start treatment, when indicated, as soon as possible after positive SARS-CoV-2 positive test result and within 10 days of symptom onset r27
- Additional multicenter interim guidance recommendations for use of monoclonal antibody products in children with mild to moderate COVID-19 at high risk for severe disease, as established by a panel of pediatric infectious disease physicians, pediatric critical care physicians, pediatric hematologists, and pharmacists, are outlined in a report in the Journal of the Pediatric Infectious Diseases Societyr28
- Defer vaccination for SARS-CoV-2 90 days or more after use of monoclonal antibody therapy r69
- Convalescent plasma
- Essentially, there are no safety and efficacy data available for children and little clinically meaningful efficacy data available for adults. Cochrane review suggests no reduction in mortality and little to no impact on clinical improvement measures r20r70
- Given paucity of available evidence, NIH does not recommend for or against use in children in the outpatient or hospital setting who do not require mechanical ventilation r6
- NIH recommends against use in mechanically ventilated pediatric patients r6
- When used, ideal timing for administration is early in course of illness, particularly in patients lacking a significant positive treatment response to remdesivir and glucocorticoids and in those with impaired humoral immunity r71
- Recommend considering (in consultation with infectious disease specialist) on a case-by-case basis for hospitalized children who fulfill emergency use authorization for high-titer convalescent plasma use r6r72
- Defer vaccination for SARS-CoV-2 90 days or more after use of convalescent plasma r69
- Baricitinib
- Immunomodulator (Janus kinase inhibitor) with emergency use authorization in place for use in combination with remdesivir in hospitalized adults and in children aged 2 years and older requiring supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation r6r72
- Given extreme lack of data in pediatric population, NIH does not recommend for or against use in combination with remdesivir when corticosteroids cannot be used r6
- Tocilizumab
- Immunomodulator (interleukin-6 inhibitor) with limited use in pediatric population for COVID-19;r73r29 efficacy data from adult trials are conflictingr72
- Emergency use authorization is available for use in combination with systemic glucocorticoids in children aged 2 years and older requiring supplemental oxygen, noninvasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation r74
- NIH does not recommend for or against use in combination with dexamethasone for hospitalized children with COVID-19 r6
Avoid potential harmful therapies not supported by evidence for treatment of acute COVID-19 in pediatric patients (outside of clinical trials), such as the following: r4
- Interleukin-1 receptor antagonists (eg, anakinra)
- Colchicine
- ACE inhibitors and angiotensin receptor blockers
- Lopinavir and ritonavir (HIV antivirals)
- Chloroquine and hydroxychloroquine
- Azithromycin, without suspicion of bacterial infection
- Ivermectin
- Nebulized interferon beta-1a
Thromboprophylaxis
- Data regarding risk of thrombotic events in children with acute COVID-19 and effectiveness of thromboprophylaxis are limited r4
- Individualized approach to thromboprophylaxis with consideration of thrombotic and hemorrhagic risk factors in children with acute COVID-19 is recommended r4
- Early ambulation and lower extremity compression garments and devices are low risk and easily implemented precautionary measures
- Some experts recommend prophylactic low molecular weight heparin for hospitalized children with COVID-19 or MIS-C at highest risk for thrombosis r75
- Higher risk patients for venous thromboembolism may include, but are not limited to, pediatric patients with elevated D-dimer results, risk factors for severe COVID-19 illness, and general risk factors for thromboembolic events (eg, obesity, family history, chronic inflammatory conditions)
- Follow institutional guidelines to help direct care decisions regarding use of antiplatelet medications and anticoagulation r4
Drug therapy
- Corticosteroids r6
- Dexamethasone
- Dexamethasone Oral solution; Children and Adolescents: The NIH guidelines recommend 0.15 mg/kg/dose (maximum dose of 6 mg) PO once daily for up to 10 days for pediatric patients requiring high-flow oxygen, noninvasive or invasive mechanical ventilation, or ECMO. Not routinely recommended for pediatric patients requiring only low oxygen support. Use in pediatric patients who are profoundly immunocompromised should be considered on a case-by-case basis.
- Antiviral RNA-polymerase inhibitors
- Remdesivir
- Avoid in patients with ALT level more than 5 times the upper reference limit and when estimated GFR is less than 30 mL/minute/1.73 m² r23
- Can consider shorter treatment duration in mild to moderate disease
- Remdesivir Solution for injection; Neonates weighing 3.5 kg or more†: 5 mg/kg/dose IV once on day 1, followed by 2.5 mg/kg/dose IV once daily for 2 days is suggested by the FDA in the Emergency Use Authorization (EUA).
- Remdesivir Solution for injection; Infants and Children 1 to 11 years weighing at least 3.5 kg†: 5 mg/kg/dose (Max: 200 mg/dose) IV once on day 1, followed by 2.5 mg/kg/dose (Max: 100 mg/dose) IV once daily for 2 days is suggested by the FDA in the Emergency Use Authorization (EUA).
- Remdesivir Solution for injection; Children and Adolescents 12 to 17 years weighing less than 40 kg†: 5 mg/kg/dose IV once on day 1, followed by 2.5 mg/kg/dose IV once daily for 2 days is suggested by the FDA in the Emergency Use Authorization (EUA).
- Remdesivir Solution for injection; Children and Adolescents 12 to 17 years weighing 40 kg or more: 200 mg IV once on day 1, followed by 100 mg IV once daily for 2 days. According to the NIH, up to 5 days of therapy may be considered for patients with new/increasing need for oxygen but who cannot be admitted to the hospital because resources are limited.
- For admitted patients with COVID-19
- Remdesivir Solution for injection; Neonates weighing 3.5 kg or more NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO)†: 5 mg/kg/dose IV once on day 1, followed by 2.5 mg/kg/dose IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement.
- Remdesivir Solution for injection; Infants and Children 1 to 11 years weighing at least 3.5 kg NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO)†: 5 mg/kg/dose (Max: 200 mg/dose) IV once on day 1, followed by 2.5 mg/kg/dose (Max: 100 mg/dose) IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement.
- Remdesivir Solution for injection; Children and Adolescents 12 to 17 years weighing less than 40 kg NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO)†: 5 mg/kg/dose IV once on day 1, followed by 2.5 mg/kg/dose IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement.
- Remdesivir Solution for injection; Children and Adolescents 12 to 17 years weighing 40 kg or more NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO): 200 mg IV once on day 1, followed by 100 mg IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement. The NIH recommends treatment for 5 days or until hospital discharge.
- SARS-CoV-2 protease inhibitor antivirals
- Nirmatrelvir-ritonavir r64
- Do not use in severe hepatic impairment (Child-Pugh Class C).
- Use with caution in preexisting liver disease.
- Nirmatrelvir Oral tablet, Ritonavir Oral tablet; Children and Adolescents 12 years and older weighing 40 kg or more: 300 mg nirmatrelvir (two 150 mg tabs) and 100 mg ritonavir (one 100 mg tab) taken together by mouth twice daily for 5 days. Start as soon as possible after the positive test for SARS-CoV-2 and within 5 days of symptom onset.
- Reduce dose to 150 mg nirmatrelvir and 100 mg ritonavir PO twice daily when eGFR is at least 30 but less than 60 mL/minute.
- Do not use when eGFR is less than 30 mL/minute.
- Antiviral monoclonal antibodies for SARS-CoV-2
- Bebtelovimab
- Bebtelovimab Solution for injection; Children and Adolescents 12 to 17 years weighing 40 kg or more: 175 mg as a single intravenous injection. Administer as soon as possible after positive test for SARS-CoV-2 and within 7 days of symptom onset.
- Sotrovimab r76
- Sotrovimab Solution for injection; Children and Adolescents 12 to 17 years weighing 40 kg or more: 500 mg as a single IV infusion. Give as soon as possible after the positive test for SARS-CoV-2 and within 7 days of symptom onset.
- Janus kinase (JAK) inhibitor
- Baricitinib r77
- Baricitinib Oral tablet; Children 2 to less than 9 years: 2 mg PO once daily for 14 days or until hospital discharge, whichever comes first. The NIH COVID-19 guidelines state there are insufficient data to recommend either for or against use in pediatric patients.
- Baricitinib Oral tablet; Children and Adolescents 9 years of age and older: 4 mg PO once daily for 14 days or until hospital discharge, whichever comes first. The NIH COVID-19 guidelines state there are insufficient data to recommend either for or against use in pediatric patients.
- Reduce dose from 2 mg PO daily to 1 mg PO daily, and 4 mg PO daily to 2 mg PO daily, when eGFR is at least 30 but less than 60 mL/minute.
- Reduce dose from 4 mg PO daily to 1 mg PO daily when eGFR is at least 15 but less than 30 mL/minute. Do not use in children aged 2 to less than 9 years when eGFR is less than 30 mL/minute.
- Do not use when eGFR is less than 15 mL/minute.
- Interrupt therapy if absolute lymphocyte count or absolute neutrophil count decreases to less than 200 cells/µL or 500 cells/µL respectively.
- Interrupt therapy if AST or ALT increases and drug-induced liver injury is suspected.
- Interleukin-6 (IL-6) receptor-inhibiting monoclonal antibody
- Tocilizumab r78
- Tocilizumab Solution for injection; Children and Adolescents 2 years and older weighing 30 kg or more: 8 mg/kg (max: 800 mg) IV infusion once. If symptoms worsen or do not improve, 1 additional dose may be administered at least 8 hours after the first. The EUA requires concurrent use with a systemic corticosteroid. According to the NIH COVID-19 treatment guidelines, data are insufficient to recommend for or against use in hospitalized children with COVID-19 or multisystem inflammatory syndrome.
- Tocilizumab Solution for injection; Children and Adolescents 2 years and older weighing less than 30 kg: 12 mg/kg IV infusion once. If symptoms worsen or do not improve, 1 additional dose may be administered at least 8 hours after the first. The EUA requires concurrent use with a systemic corticosteroid. According to the NIH COVID-19 treatment guidelines, data are insufficient to recommend for or against use in hospitalized children with COVID-19 or multisystem inflammatory syndrome.
- Do not use with elevated ALT or AST above 10 times the upper limit of the reference range
Nondrug and supportive care
- Measures intended to avoid secondary spread of virus from infected and potentially infected individuals
- Quarantine in instances of possible infection after close contact exposure to SARS-CoV-2
- Close contact exposure is defined as being within 6 feet for 15 minutes or more over a 24-hour period to someone with COVID-19 r13
- CDC's recommended best practice is to obtain test for SARS-CoV-2 at day 5 after exposure for all individuals exposed, when feasible r24
- Patients without full vaccine imparted immunity (ie, unvaccinated patients and patients not yet boosted after more than 6 months of time has elapsed from last dose of primary mRNA series or more than 2 months after Johnson and Johnson vaccine) r24
- Quarantine for 5 days then strict mask use for an additional 5 days
- If quarantine is absolutely not feasible, well-fitting mask use at all times when around others for 10 days after exposure is imperative
- If symptoms develop, begin isolation measures and obtain immediate testing
- Measures for individuals who are fully vaccinated and have received booster within appropriate time frame r24
- No quarantine is necessary
- Recommend mask wearing for 10 days after exposure
- If symptoms develop, begin immediate quarantine until negative test confirms symptoms are not attributable to COVID-19
- Use health care facility–based infection prevention and control measures for patient with suspected or confirmed SARS-CoV-2 infection r79
- Precaution measures
- Minimum required are standard, contact, droplet precautions, and airborne precautions during aerosol-generating procedures
- Standard precautions include use of gown, gloves, and N95 respirator with eye protection (goggles or face shield) or air purifying respirator that provides eye protection
- Patient placement
- Preferred is single patient room with dedicated bathroom; close door when safe to do so
- Limit patient transport outside of room
- Best option is to dedicate a specific unit and individual health care providers to care for patients
- Personal protective equipment
- Adhere to standard precautions; use N95 or higher level respirator, gown, gloves, and eye protection
- Aerosol generating procedures
- Avoid procedures with potential to generate aerosols when alternatives exist (eg, medications delivered by metered dose inhaler in lieu of nebulized medications)
- Cautiously perform procedures that have potential to generate aerosol in an airborne infection isolation room, when possible
- Visitation
- In general, it is preferred to limit in-person visitation; adhere to local, state, and federal regulations
- Environmental infection controls
- Use dedicated medical equipment (eg, stethoscope)
- Maintain routine cleaning and disinfection procedures as per hospital protocol
- Leave cell phones, laptops, and other devices outside room r4
- COVID-19 isolation measures and transmission-based precautions for those infected with virus (with or without symptoms): r79
- Most patients who are positive for COVID-19: use symptom-based strategy rather than test-based strategy (recommended). Exceptions include patients with severe immunocompromise and those with severe COVID-19 infection
- Use the most severe degree of illness (mild to moderate, severe to critical) during clinical course of illness to determine isolation protocol/duration of transmission-based precautions
- Patients with asymptomatic or symptomatic mild and moderate COVID-19 infection without severe immunocompromise
- Isolate for 5 days and, if asymptomatic or if symptoms are resolving (without fever for 24 hours), follow that by 5 days of mask wearing when around others r24
- Patients with severe to critical COVID-19 infection and patients who have moderate to severe immunocompromise:
- Consult with infectious disease and infection control experts to determine criteria for discontinuing isolation measures and transmission-based precautions
- Minimum symptom-based requirements for discontinuing isolation and precautions include all of the following:
- At least 10 days and up to 20 days have passed since onset of first symptom
- At least 24 hours have passed since last fever (without use of antipyretics)
- Symptoms have improved
- May require isolation and precautions for at least 20 days from onset of symptoms (or positive diagnostic test if asymptomatic)
- Some immunocompromised patients remain infectious for 20 days or more after start of initial symptoms; rarely, replication-competent virus is recovered from severely immunocompromised patients months after initial positive SARS-CoV-2 test result
- A minority of patients with severe and critical illness are infectious 15 days after onset of symptoms; replication-competent virus has not been detectable in patients with severe or critical illness after 20 days from onset of symptoms
- Consider using test-based strategy of SARS-CoV-2 nucleic acid testing before discontinuing isolation and transmission-based precautions
- Before discontinuing isolation measures, test-based strategy requires both of the following:
- 2 consecutive negative reverse transcription polymerase chain reaction test results to detect SARS-CoV-2 RNA spaced 24 hours or more apart
- Improvement in symptoms
- Approach to empiric COVID-19 isolation and transmission-based precaution measures for patients with suspected COVID-19 (ie, rule out SARS-CoV-2 infection) admitted to health care facility r79
- Empiric isolation and transmission-based precautions may be discontinued with negative results from at least 1 negative nucleic acid amplification test to detect SARS-CoV-2 RNA
- A second negative test for SARS-CoV-2 RNA may be required if a high level of clinical concern exists for infection despite 1 negative test before clearing from isolation and other transmission-based precautions
Comorbidities
- Children with immunodeficiency or immunocompromise
- Consider managing in consultation with infectious disease specialist. COVID-19 treatment-specific therapies and pharmacotherapeutics may be indicated
- On a case-by-case basis, consider using glucocorticoids to treat patients who have severe COVID-19 based on the theoretical risk of infection worsening in patients with significant immunocompromise r6
- Consider risk and benefit of pharmacologic immune suppression in consultation with appropriate prescribing specialist to determine if temporary reduction in pharmacologic immunosuppression is warranted r23
- Some experts recommend reducing T-cell immunosuppression, when applicable, in infected children r47
- Isolation measures can be modified to 20 days (instead of 10 days for immunocompetent patients) after symptom onset and after resolution of fever and improvement of other symptoms r13
- A test-based strategy requiring 2 negative tests for SARS-CoV-2 RNA before discontinuing isolation measures can be considered in consultation with infectious disease experts
- A third dose of vaccine, after the 2-dose primary mRNA COVID-19 vaccine series, is recommended for patients aged 5 years and older with moderate to severe immunocompromise r15
- Children at high risk for severe COVID-19
- Consider management in consultation with an infectious disease specialist; COVID-19 treatment-specific therapies and pharmacotherapeutics may be indicated
- Children with asthma
- Avoid aerosol-generating procedures when possible. Consider administering respiratory medications via metered dose inhaler with spacer and/or dry powder inhaler (ie, Turbuhaler or Diskus) rather than nebulization r4
- Children with croup
- Consider early use of steroids in effort to prevent return visits to health care facility and reduce risk for admission r4
- Avoid aerosol-generating procedures when possible; consider using epinephrine via metered dose inhaler with spacer or subcutaneous/intramuscular dosing instead of nebulized epinephrine when indicated for severe croup r4
Special populations
- Neonates
- Rate of infection in neonates does not appear to be affected by mode of delivery, method of feeding, or contact with mother with suspected or confirmed SARS-CoV-2 infection r10
- Obtain nucleic acid amplification test result for SARS-CoV-2 in neonates born to mothers with suspected or confirmed COVID-19 at about 24 hours of life; repeat testing is recommended if initial test is negative at 48 hours of life r10
- A single test between 24 and 48 hours of life is acceptable in asymptomatic infants who may be discharged to home before 48 hours of life r10
- Maintain high suspicion for alternate and/or concomitant diagnosis responsible for symptoms (eg, temperature instability, cough, difficulty breathing) that may be suggestive of COVID-19 in neonates r10
- Isolate mothers with suspected or confirmed SARS-CoV-2 infection and their neonates from healthy mothers and neonates r10
- Rooming both neonate and mother together is recommended in most instances; CDC stresses importance of maternal autonomy in the decision making process
- Avoid isolating neonates in neonatal ICU unless clinical condition warrants neonatal ICU care
- Encourage measures to minimize risk of transmission, including general infection prevention and control measures (eg, hand hygiene, wearing a mask) by caregivers while breastfeeding and caring for neonate r10