Paediatric covid management and MISC management

Paediatric covid

1. PAEDIATRIC COVID AND MIS-C MANAGEMENT Prof.D r .P.M.Suresh MD,DCH HOD - Department of Pediatrics KKGMC

2. WHEN TO SUSPECT? Fever, headache, myalgia, fatigue ,tiredness, coryza , cough, sorethroat , rapid breathing OR Diarrhea, vomiting, abdominalpain , intussusception, DKA OR Poorfeeding i n an infant, loss of taste or smell in >8year s OR Rash, conjunctival congestion, mucositis , shock OR Asymptomatic but has a close household contact with a COVID-19 case.

3. WHOM TO TEST? Test Done: SARS COV-2 RTPCR

4. Etiology & Pathogenesis

5. Clinical Features

6. How to Approach? Asymtomatic : Home isolation ( tele consultation SOS) Mild : Home Isolation ( tele consultation SOS) or COVID Care Centre If there is high grade fever for > 3-4 days investigate for alternate dx and also CBC , CRP, Urine R/E, Blood C&S, CXR Moderate severe: Admit in Covid ward and do CBC , ESR,CRP, Creatinine, AST/ALT, Alb ,, PT, INR, APTT, D-dimer , blood culture , CXR, Inv for other tropical infs (Dengue/MP/ Lepto IgM , Scrub typhus etc as clinically directed ). Repeat investigations every 48 hours. Severe Disease: Admit in Covid PICU and do CBC , SE, RFT, LFT , Bloodculture , CXR, ABG ,CRP, Ferritin , Procalcitonin , LDH , D dimer, PT , APTT, NTproBNP , Trop I, CKMB, ECG , ECHO. Repeat investigations after 48 hours . CRITICAL DISEASE ARDS, Sepsis, Shock, MODS, Acute thrombosis, MIS-C

7. Treatment Mild: Paracetamol 10-15 mg/kg, 4-6hrly for fever, Adequate hydration, ORS , Zinc if diarrhea (+), Counsel about danger signs Admission if no access to health care or with primary disease like CHD/CKD/CLD/CNS/ hematological / PID No Antibiotics for < 3 days of illness If > 3 days of high fever - Amoxclav /Azithromycin

8. Treatment Moderate severe: Paracetamol 10-15 mg/kg, 4-6hrly for fever Oral feeding or IV fluids as per clinical need Correct dehydration, if present Oxygen (nasal prongs, FM , NRM) if SpO2 <94 % or increasing distress. Target SpO2 : 94% Awake proning in >8 yrs old (if possible, 2 hourly position change) Abx - Amoxclav /Azithromycin or Inj Ceftrioxone + Inj Amikacin as clinical need. Steroids Remdesivir (on case to case) Safety and not proved in Children

9. Moderate severe ,O2 Therapy < 5 years- Nasal cannula 5-10 yrs – Ped O2 mask >10 yrs - NRM mask

10. Treatment Severe Disease Paracetamol 10-15 mg/kg, 4-6 hrly for fever Correct dehydration. Oral feeding or IV fluids as clinical need. Oxygen if SpO2< 94% or increasing distress. Escalate to CPAP, HFNC/ BiPAP /NIV/IMV as clinical need. Target SpO2: 94 % Antibiotic amoxclav /ceftriaxone + amikacin Consider awake proning in older children Steroids Anticoagulants. Remdesivir (on case to case)basis Tocilizumab (on case to case)basis

11. Pediatric ARDS-Definition Acute onset (within 7 days of known clinical insult) Re spiratory failure (not fully explained by cardiac failure or fluid overload) Chest imaging findings of new infiltrate consistent w ith acute parenchymal disease .

12. Management/treatment of ARDS Mild ARDS High flow nasal oxygen (start with 0.5 L/kg/min can increase to 2 L/kg/min) or non-invasive ventilation ( BiPAP or CPAP). Moderate – Severe ARDS Lung protective mechanical ventilation . 1) Low tidal volume (4-8 ml/kg); plateau pressure <28-30 cmH 2 O; MAP < 18- 20 cmH 2 O; driving pressure <15 cmH 2 O; PEEP 6-10 cmH 2 O (or higher if severe ARDS); FiO 2 < 60% 2) Sedoanalgesia ± neuromuscular blockers 3) Cuffed ETT, inline suction, heat and moisture exchange filters (HMEF) Avoid frequent disconnection of ventilator circuit, nebulization or MDI Restrict fluids Prone position in hypoxemic children if they tolerate it Daily assessment for weaning; enteral nutrition within 24 hrs, full feeds by 48 hrs Transfusion trigger Hb <7g/ dL if stable oxygenation & haemodynamics Hb<10 g/ dL if refractory hypoxemia or shock

13. Management of shock NS fluid bolus 10-20 ml/kg cautiously over 30-60 minutes with early vasoactive support ( epinephrine) Start antimicrobials within the first hour, after taking blood cultures. I notropes ( milrinone or dobutamine ) if myocardial dysfunction persists. Hydrocortisone if there is fluid refractory catecholamine resistant shock (avoid if already on dexamethasone or methylprednisolone) Once stabilized, restrict IV fluids. Initiate enteral nutrition – sooner the better Transfusion trigger Hb <7g/ dL if stable oxygenation and haemodynamics , and <10 g/ dL if refractory hypoxemia or shock

14. Drugs Steroids: Dexamethasone-0.15 mg/kg (Max 6 mg) IV or oral OD Equivalent dose of Methylprednisolone/ Prednisolone @ 0.8-1mg/kg/day in 2-3 div doses Duration: 5 to14 days as per clinical need Anticoagulation (LMWH ): Prophylactic: 0.5 mg/kg/SC BD Therapeutic dose: 1mg/ kg SC BD Age group : 2 mo -18 yrs Duration: 14 days/discharge whichever earlier for prophylaxis Pre-requisite-No contraindication or high risk for bleeding (clinically assessed) Indication-prophylactic therapy Severe and critical disease Moderate disease with ≥2risk factor for VTE Elevated D-dimers >500 ng /ml and rising) Indication- therapuetic Established thrombosis /non hemorrhagic stroke

15. RISK FACTORS FOR THROMBOEMBOLISM . > 14 years Obesity Nephrotic syndrome Cong / Acquired cardiac disease( eg TOF) Previous or family h/o VTE Known thrombophilia Post- splenectomy Hemoglobinopathy Cystic fibrosis Central line Mechanical ventilation NO ROLE Hydroxychloroquine , chloroquine , ivermectin , routine azithromycin, Vitamins C, D, A, Zinc (unless diarrhoea )

16. Drugs Remdesivir : (Not recommended in MOHFW guidelines) Dose >40kg:200mg on day1& 100mg OD x 4 days 3.5-40kg:5mg/ kgonday 1;2.5mg/ kgOD ( off label ) Duration 5 days Indication Moderate and rapidly progressing pneumonia S evere / critical disease (pneumonia) Duration: before 7-10 days from symptom onset. When to avoid? OT/PT>5times normal Creatinine clearance<30ml/min/m 2

17. Drugs Tocilizumab (Not Recommended in MOHFW guidelines) Dose- 8 mg/kg (max 800 mg) IV infusion over 4 hrs. If no response or worsening , can repeat in 8-24 hrs Pre-requisite- No active bacterial, fungal, or tubercular infection Indication - Moderate/Severe with rapid worsening within 7 days of illness (within24-48hrs of worsening), increasing inflammatory markers (CRP>75 and/or IL-6) despite steroids.

18. DISCHARGE CRITERIA Resolution of clinical symptoms. SpO2>94% off oxygen for 3 days. Negative RT-PCR not needed for discharge. Followed by home isolation (total 17 days from symptom onset)

19. Multisystem Inflammatory Syndrome in Children (MIS-C)

20. World Health Organisation (WHO ) Definition Age 0 to 19 years Fever >/= 3 days and 2 of the following Clinical Features : i) Rash ( bilateral, non purulent conjunctivitis or mucocutaneous inflammatory signs( oral, hands, feet) ii) Hypotension/ shock iii) Myocardial dysfunction, pericarditis, valvulitis , coronary abnormalities ( ECHO findings or elevated Trop I or NT-Pro BNP iv) Coagulopathy ( PT, aPTT , D-Dimer) v) Acute GI problems ( diarrhoea , vomiting, pain abdomen ) v i)And high (CRP, ESR, Procalcitonin ) with e/o COVID 19 by RTPCR, antigen, serology or likely contact with COVID -19 cases and No microbiological cause

21. Management MIS-C- use of biologicals . PICU- if cardiac dysfunction, coronary involvement, shock or MODS. IVIG to be given slower (over 48 hours) in children with cardiac failure/ fluid overload Taper steroids over 2-3 weeks. Aspirin 3-5 mg/kg/day, maximum 75 mg/day in all children for 4-6 weeks (with platelet count >80,000/ μL ) for at least 4-6 weeks or longer for those with coronary aneurysms . Low molecular weight heparin (Enoxaparin ) 1 mg/kg/dose twice daily s/c in >2 months (0.75mg/kg/dose in <2 months) if patient has thrombosis or giant aneurysm with absolute coronary diameter ≥8 mm or Z score ≥10 or in ECHO -LVEF <30% For children with cardiac involvement, repeat ECG 48 hourly & repeat ECHO at 7–14 days and between 4 to 6 weeks, and after 1 year if initial ECHO was abnormal

22. COVID IN NEONATES

23. COVID TESTING PROTOCOL- NEONATES RT-PCR for SARS-CoV-2 is the test of choice Timing of test: Test - if Mother with COVID-19 detected within 14 days before or within 2 days after delivery Test - Between 24-48 hours of age . In case of early discharge , take a pre discharge sample. R epeat test is desirable at 5-7 days of age or earlier if neonate becomes symptomatic . If the neonate requires ongoing hospital care because of prematurity and its complications, documentation of negative RT-PCR is desirable before shifting to a non-COVID area .

24. VERTICAL Transmission:- Rare, RTPCR + ve within 24 Hr sample. PERINATL Transmission:- Not uncommon Test + ve within 24 hrs-72hrs HORIZONTAL Transmission:- Test + ve after 72 hrs

25. SPECIFIC MANAGEMENT FOR NEONATES WITH COVID-19 Investigations for COVID-19 in neonates Asymptomatic or mild COVID-19 - no "routine" laboratory testing aside from RT-PCR for SARS-CoV-2. Symptomatic and moderate or severe COVID-19 - R elevant biochemical, hematologic, and coagulation tests/to rule out co-existing illness like sepsis, asphyxia, or meconium aspiration syndrome

26. Discharge policy for neonates Stable neonates exposed to SARS-CoV-2 infection and roomed-in with their mothers may be discharged along with their mothers . Stable neonates in whom rooming-in is not possible because of sick mother and who are being cared by a trained family member ► discharged from the facility by 24-48 hours of age . Mothers and family members should be counseled regarding the danger signs . Mothers should wear a triple-layered mask while breastfeeding and while providing care to the baby . Followed up for at least 14 days

27. Immunization policy for neonates 1 . Follow routine immunization policy in healthy neonates born to mothers with suspected/confirmed COVID-19 . 2. In neonates with suspected/confirmed infection, vaccination should be completed before discharge from the hospital as per existing policy . Special situations: Neonates who received intravenous immunoglobulin (IVIG) or postnatal steroids in standard dose for a shorter duration (5-10 days): Routine immunization schedule (as per national guidelines) once IVIG/steroids are discontinued .

28. Guide for using mask Masks are not recommended for children aged 5 years and under Children aged 6-11 years may wear a mask appropriately under direct supervision of parents/guardians Children aged 12 years and over should wear a mask under the same conditions as adults Ensure hands are kept clean with soap and water, or an alcohol-based hand rub, while handling masks

29. Thank You