On June 9, the Ministry of Health & Family Welfare released a set of COVID management guidelines for children below 18 years of age. These include treatment of children with asymptomatic, mild, moderate and severe symptoms. There are instructions for mask use, Remdesivir and black fungus too. More details here.
A kid while receiving handwashing training. Photo: Unicef India
Amid fear of the possibility of the COVID19 third wave affecting children, the Directorate General of Health Services under the Union health ministry has issued comprehensive guidelines for the management of the coronavirus disease among children below 18 years of age. These guidelines were released yesterday June 9.
Apart from providing detailed information on four category of COVID symptoms in children — asymptomatic, mild, moderate and severe symptoms — the new guidelines also discuss Acute Respiratory Distress Syndrome (ARDS), Multisystem Inflammatory Syndrome (MIS), antimicrobial use, and infection prevention and control.
The guidelines clearly say that Remdesivir, an emergency use authorization drug, is not recommended in children.
Fever, cough, sore throat, body aches, weakness, loss of sense of smell or taste are common symptoms of COVID19 in children.
Moderate and severe cases will experience shortness of breath. For moderate cases, the SpO2 or oxygen level will range between 90 to 93 per cent. For severe cases, it is less than 90 per cent.
For asymptomatic cases, no specific medication is required for COVID-19 infection, inform the new guidelines. However, medications for other conditions should be continued, if any. Oral fluids should be given to maintain hydration.
In mild cases, paracetamol 10-15 mg per kg per dose should be given. Process could be repeated every 4-6 hours. The health ministry has recommended oral fluids, nutritious diet, and warm saline gargles in older children and adolescents. Antimicrobials are not indicated.
The parents and guardians should monitor the counting of respiratory rate 2-3 times a day, and look for chest indrawing, bluish discoloration of body, cold extremities, urine output, oxygen saturation, fluid intake, activity level.
For moderate cases, immediate oxygen therapy should be initiated. Fluid and electrolyte balance should be maintained.
If oral intake is poor, intravenous fluid therapy should be initiated. Paracetamol 10-15mg per kg per dose should be given. Antimicrobials should be administered if there is strong suspicion of superadded bacterial infection.
For severe cases, apart from initiating immediate oxygen therapy, corticosteroids therapy should be initiated. In case of organ dysfunction, such as renal replacement therapy, organ support might be needed.
Children above 12 years of age, who have asymptomatic and mild COVID symptoms, are advised to take a six minutes of walk test under supervision of parents and guardians.
As part of this test, a pulse oximeter should be attached to the finger and the child should be made to walk in the confines of their room for six minutes continuously.
Children with a positive six-minute walk test may progress to become hypoxic (deprived of adequate oxygen supply) and early admission to hospital is recommended for observation and oxygen supplementation.
A positive test is any drop in saturation less than 94 per cent, or absolute drop of more than 3–5 per cent or feeling unwell (lightheaded, short of breath) while performing the test or at the end of six minutes.
The test can be repeated every six to eight hours of monitoring in a home setting. However, the test should be avoided in patients with uncontrolled asthma.
The advisory by the Directorate General of Health Services has suggested that children aged five years or under-5 are not required to wear masks.
However, children between the 6-11 age group may wear a mask depending on the ability to use a mask safely and appropriately under direct supervision of parents and guardians.
Children aged 12 years and above should wear a mask under the same conditions as adults.
While handling masks, ensure hands are kept clean with soap and water, or an alcohol based hand rub.
The health ministry has also advised against the use of antiviral drug Remdesivir — an emergency use authorization drug — in children.
There is lack of sufficient safety and efficacy data with respect to Remdesivir in children below 18 years of age, said the recent guidelines.
Steroids are not indicated and are harmful in asymptomatic and mild cases of COVID-19. Self-medication of steroids must be avoided, warned the advisory.
However, corticosteroids may be used in rapidly progressive moderate and severe cases. But these are not required in all children with moderate illness; they may be administered in rapidly progressive disease.
Mucormycosis, or commonly known as ‘black fungus’ is an aggressive, life-threatening infection that needs prompt diagnosis and early treatment to reduce mortality. The ministry has advised not to wait for culture results to initiate therapy as the disease is an ‘emergency’.
As part of the treatment, conventional Amphotericin B (deoxycholate) as a prolonged IV infusion through a central venous catheter is recommended. Kidney function and electrolytes should be closely monitored during the treatment.
However, those who cannot be given Amphotericin B, are advised to give Posaconazole as salvage therapy.
Meanwhile, as several states are preparing for the third wave of the pandemic, Randeep Guleria, director of New Delhi-based All India Institute Of Medical Science and a member of India’s COVID task force clarified that there is no indication as of now of children being more vulnerable to the third wave of COVID-19.