Children infected with Sars-Cov-2 should not be given remdesivir, and steroids or anticoagulants, if required, should only be given in a hospital, the Union government has said in its first set of guidelines for paediatric treatment of Covid-19.
Drawn up by the Directorate General of Health Services, the technical wing of Union ministry of health and family welfare, the guidelines advise restraint in the use of medication – similar to its new recommendations for adults recently that dropped the names of several drugs previously advised.
“There is lack of sufficient safety and efficacy data with respect to remdesivir in children below 18 years of age. HRCT chest to be done ONLY if there is worsening of symptoms…,” read the guidelines issued on Wednesday.
HRCT refers to high-resolution chest CT scans.
The guidelines also say routine treatment should include no more than typical antipyretics (fever medicine) and antitussives (drugs for cold and cough).
The recommendations come at a time when experts and officials have raised concerns regarding the overuse of drugs, which could lead to worsening of symptoms, and the use of medicines that are not approved or may be harmful.
The guidelines define mild symptoms as low grade fever, cough, rhinorrhoea, sore throat, body and headache, malaise or weakness, diarrhoea, nausea or vomiting, loss of smell or taste. Moderate disease includes pneumonia and a high respiratory rate (which was defined differently for different ages) and oxygen saturation between 90-93 % on room air.
Severe has been defined when oxygen saturdation (or SpO2 level) dropped below 90% and the child showing symptoms of severe pneumonia, acute respiratory distress syndrome, septic shock, or multi-organ dysfunction syndrome.
Experts say the guidelines are pertinent. “This is exactly what we have been following and advising as part of the Indian Academy of Paediatricians. There is no point in overprescribing medicines or tests as children by and large recover with symptomatic treatment,” said Dr Rahul Nagpal, director, paediatrics department, Fortis Healthcare.
“But what is important is to accurately categorise mild, moderate and severely ill children, and observe them closely. Observation is also an integral part of Covid-19 treatment and pay attention towards red flags that would require immediate hospitalisation,” he added.
For asymptomatic cases
The guidelines recommend infants and younger children stay under immediate care of parents or guardians in home isolation. No specific medication is required but any ongoing medication for other illnesses should be continued. The child infected must follow Covid precautions like wearing a mask, washing hands frequently and keeping distance.
The guidelines advise adequate intake of fluids to maintain hydration and a nutritious diet, and advise older children and family to stay connected and “engage in positive talks through phone, video calls, etc”.
Should any symptoms worsen, the family must immediately consult a doctor. No routine investigations (tests) are needed.
For mildly symptomatic cases
They should also remain in home isolation and must follow Covid-appropriate behaviour. For fever, they can be given paracetamol in a dose calculated at the rate of 10-15mg per kg of body weight. This dose can be repeated every 4-6 hours if needed. For cough, throat soothing agents and warm saline gargles in older children and adolescents is recommended.
Children in this category of illness should hydrate well and take a nutritious diet. No other Covid-19 specific medication is needed, especially antimicrobial drugs. Parents or attendants need to maintain a monitoring chart, which includes counting the respiratory rate 2-3 times a day, and keeping a lookout for specific symptoms: chest indrawing (inward movement of the lower chest wall), bluish discolouration of the body, cold extremities, any abnormality in urination, oxygen saturation changes, fluid intake or activity level changes. Parents or caregivers must contact a doctor in case of deterioration of symptoms. No investigations are required.
For moderately sick cases
Such children must be taken to a hospital or a Covid-care facility, where they must be put on oxygen therapy and their fluid and electrolyte balance, especially oral fluids (breast feeds in infants), must be maintained by initiating intravenous fluid therapy if oral intake is poor. Corticosteroids are not required in all children with moderate illness; they may be administered in rapidly progressive disease, and anticoagulants may also be indicated, the guidelines advise.
For fever (temperature >38°C or 100.4°F) a child should be given paracetamol 10-15mg/kg/dose that may be repeated every 4- 6 hours. Antimicrobials need to be administered if there is evidence or strong suspicion of bacterial infection, and supportive care for comorbid conditions, if any, must be initiated.
The guidelines prescribe a set of tests but suggest that HRCT scans must be done only in a rational manner.
For severe cases
They should be immediately put on oxygen therapy in a facility and fluid and electrolyte balance must be maintained. They will also need to start on corticosteroids and anticoagulants as indicated. In case there is Acute Respiratory Distress Syndrome (ARDS) or shock, necessary management to be initiated; antimicrobials should be administered if there is evidence or strong suspicion of superadded bacterial infection. The child may need organ support in case of organ dysfunction such as renal replacement therapy etc.
Guide for using masks by children
Children aged 5 years and under should not be required to wear masks. Children aged 6-11 years may wear a mask depending on their ability to use it safely and appropriately under direct supervision of parents or guardians; those aged 12 years and over should wear a mask under the same conditions as adults; and should ensure hands are kept clean with soap and water, or an alcohol based hand rub, while handling masks.