Diagnosis, Treatment, and Prevention of 2019 Novel Coronavirus Infection in Children: Experts' Consensus Statement

Shen, K., Yang, Y., Wang, T. et al. Diagnosis, treatment, and prevention of 2019 novel coronavirus infection in children: experts’ consensus statement. World J Pediatr (2020). https://doi.org/10.1007/s12519-020-00343-7

Review written by:

Gabriel Pomerantz, edited by Elizabeth Harty and Lillian Zerihun

Yellow - This article presents a set of recommendations by an expert consensus panel. Cited evidence related to infection SARS-nCo-V is essentially retrospective and descriptive. Recommendations regarding diagnosis and management of COVID-19 in children is based on panelist clinical experience with prior Coronavirus strains, community acquired pneumonia, and very limited data on early experiences with pediatric COVID-19 infection in China.

When weighing clinical suspicion for COVID-19 infection in a child, consider the following laboratory examinations:

1.  A CBC panel (typically the white blood cell count is normal or decreased with lymphopenia).

2.  Most patients have elevated C-reactive protein levels and erythrocyte sedimentation rates.

3.  Severe cases show high D-dimer levels and decreased blood lymphocyte counts.

4.  In addition, perform a throat swab when checking for either viral pharyngitis or COVID-19 to test for 2019-nCoV nucleic acids.

SARS-nCoV infection should be suspected in patients who meet any one of the following epidemiologic criteria, and any two of the criteria in clinical manifestations:


Epidemiological History

1.  Children with travel history or residence in areas with high local transmission within a period of 14 days.

2.  Children with a history of coming in close proximity to patients with fever or respiratory symptoms, in

addition to travel history or residence in areas of high local transmission within a 14-day period.

3.  Children in close contact with 2019-nCoV infected people

4.  Newborns delivered by mothers infected with the virus


Clinical Manifestations

1.  Fever, fatigue, dry cough

2.  Chest CT scan, which typically shows multiple peripheral plaques and interstitial changes, bilateral ground glass opacities, or frank infiltrates

3.  In the CBC panel, white blood count is normal or decreased with decreased lymphocyte count.

Confirmation of diagnosis requires one of the following:

1.  Use RT-PCR to test respiratory tract or blood samples for positive 2019-NCoV nucleic acid.

2.  Gene sequencing of respiratory tract or blood sample is highly homologous with 2019-NCoV. [Not used in U.S.]


Clinical Classifications:

1. Asymptomatic infection (silent infection). 2. Viral Pharyngitis. 3. Mild Pneumonia 4.  Severe Pneumonia (O2 saturation < 92%, hypoxia, somnolence, coma, or convulsion, food refusal with signs of dehydration).

Critical Cases:  Those who meet any of the following require ICU care – 1. Respiratory failure   2. Shock 3. Organ failure


General treatment includes bed rest and supportive treatment including hydration (getting in enough fluids and electrolytes) monitoring vital signs and o2 saturation; measuring blood and urine routines.


Symptomatic treatment includes patients whose fever exceeds 101.5 F with use of fever reducer, or physical cooling (i.e. warm water bath).  If hypoxia appears use oxygen therapy when appropriate, including nasal cannula or mask. High flow nasal cannula or mechanical ventilation should be used with refractory or profound hypoxia.


Antiviral Therapy includes Interferon-α nebulizer treatment and Interferon-α2b spray for high risk populations. [Anecdotal based on Chinese clinical experiences treating bronchiolitis, SARS, hand-foot-mouth disease and other viral respiratory infections in children.] The safety and efficacy of Lopinavir/Ritonavir has yet to be determined.


Use of other agents such as antibiotics (avoid irrational usage with children and actively collect samples for pathogen analysis and timely or rational use of antibiotics or antifungal drugs.) Glucocorticoids or Immunoglobulins can be used in severe disease (anecdotal, based in part on experience with community acquired pneumonias).

Use of Chinese Traditional Medicines is presented in the context of traditional Chinese clinical classifications. This section offers detailed recommendations and insight into the application of these remedies, but does not include any citation of evidence.


Severe and Critical Cases: Respiratory support should only be applied in an invasive manner after undergoing non-invasive ventilation for 2 hours without improvements, or if respiratory failure. The invasive mechanical ventilation should adopt low tidal volume “lung protective ventilation strategy” to reduce ventilator related lung injury. Prevent complications and secondary infection, and use circulatory support with vasoactive drugs. Prone ventilation or ECMO can be applied.


Release and discharge criteria

Confirmed patients can be discharged from isolation or transferred to the corresponding departments for treatment of other diseases if all the following criteria are met:

1.  The body temperature returns to normal for longer than 3 days;

2.  The respiratory symptoms improve;

3.  Respiratory pathogen nucleic acid is negative two consecutive times (with sampling interval at least 1

day).

Review Notes
 
  1. These recommendations are on behalf of the World Journal of Pediatrics, and as such are not in accordance with a national medical association such as the American Society of Pediatrics.

  2. Recommendations are based on anecdotal/clinical experience of the expert panel, with no prospective or randomized controlled study data related to SARS-nCoV. By necessity (early in the pandemic) the limited data cited regarding SARS-nCoV is descriptive only, and all other data relates to management of other viral agents or community acquired pneumonia. Numerous recommendations (e.g., inhaled interferons, traditional Chinese medicines) are widely accepted in China but may not be applicable in U.S. populations.

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