The Comprehensive Guidelines for Management of COVID-19 in CHILDREN and ADOLESCENTS (below 18 years) were reviewed by the group of experts in view of the current surge mainly attributed to the Omicron variant of concern. The available data from other countries suggests that disease caused by the Omicron variant is less severe; however, there is need for a careful watch, as the current wave evolves. These guidelines are dynamic, and will be reviewed and updated, on availability of new evidence.
The experts have assessed the available evidence and overall, the management remains unchanged, barring a few changes outlined below.
Title of the document has been changed from Comprehensive Guidelines for Management of COVID-19 in CHILDREN (below 18 years) to Comprehensive Guidelines for Management of COVID-19 in CHILDREN and ADOLESCENTS (below 18 years).
Use of antivirals or monoclonal antibodies is not recommended for children less than 18 years of age, irrespective of the severity of infection.
For diagnosing MIS-C, caution should be exercised while interpreting an isolated increase in COVID antibodies.
The CRP level for diagnosis of MIS-C has been revised as >5mg/dL.
If steroids are used, they should be tapered over 10-14 days, subject to clinical improvement.
Use of anticoagulants has been revised.
New section on post-COVID care has been added.
Attention is drawn to the following MoHFW guidelines:
Toxic shock syndrome (staphylococcal or streptococcal)
MIS-C with Kawasaki Disease (KD) phenotype is characterised by fever, conjunctival redness, oropharyngeal findings (red and/or cracked lips, strawberry tongue), rash, swollen and/or erythematous hands and feet and cervical lymphadenopathy
To know information about Stepwise investigations in a patient with MIS-C and Management of MIS-C Click Here.
Appropriate supportive care is needed preferably in ICU for treatment of cardiac dysfunction, coronary involvement, shock or multi-organ dysfunction syndrome (MODS)
IVIG to be given slower (over up to 48 hours) in children with cardiac failure/ fluid overload
Use biologicals only after expert consultation and at tertiary care only
Taper steroids over 2-3 weeks with clinical and CRP monitoring
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 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
Infection Prevention and Control (IPC)
Every COVID care facility should have a multidisciplinary hospital infection control committee; key components of infection control strategy are:
Contact precautions and hand hygiene
Cough etiquette/respiratory hygiene
Well ventilated rooms
Monitor healthcare associated infections
Train all health care workers to develop IPC skills
Environment cleaning, disinfection and sanitation
Cleaning/disinfection of frequently touched surfaces/equipment
Cleaning and disinfection of linen
Safe management of bio-medical waste
Triple layer mask to be worn by patient, as per guidance below
Masks for care givers (home/hospital)
Guide for using mask
Masks are not recommended for children aged 5 years and under
Children aged 6-11 years may wear a mask depending on the ability of child to use a mask safely and 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
Antimicrobial use guide
COVID-19 is a viral infection, and antimicrobials have no role in the management of uncomplicated COVID-19 infection
Asymptomatic and mild cases: antimicrobials are not recommended for therapy or prophylaxis
Moderate and severe cases: antimicrobials should not be prescribed unless there is clinical suspicion of a superadded infection
Septic shock: empirical antimicrobials (according to body weight) are frequently added to cover all likely pathogens based on clinical judgement, patient host factors, local epidemiology and antimicrobial policy of the hospital
Use of steroids and anticoagulants
Steroids are not indicated and are harmful in asymptomatic and mild cases of COVID-19
Indicated only in hospitalized severe and critically ill COVID-19 cases (Under Strict Supervision)
Steroids should be used at the right time, in right dose and for the right duration
Indications and recommended dose of corticosteroids – may be used in rapidly progressive moderate and all severe cases
Dexamethasone 0.15 mg/kg, maximum dose 6 mg once a day OR
Methylprednisolone 0.75 mg/kg, maximum dose 30 mg once a day
Continue for 5-7 days and taper, up to 14 days, depending on clinical assessment on daily basis
Avoid steroids in first 3-5 days since onset of symptoms as it prolongs viral shedding
Not indicated routinely
All hospitalized children should be monitored for thrombosis; on suspicion, confirm by appropriate investigations and start on low molecular weight heparin in therapeutic doses for period of 12 weeks with monitoring
Prophylactic anticoagulant is indicated in following circumstances (the decision to administer prophylactic anticoagulation must be balanced with the child's bleeding risk):
strong personal or family history of VTE
an indwelling central venous line and two or more additional risk factors
four or more risk factors
(*Predisposing risk factors for development of thrombosis – personal history of venous thrombotic events (VTE), family history of first-degree relative with VTE, presence of central venous line, decreased mobility from baseline, burns, active malignancy, estrogen therapy, flare of inflammatory disease, morbid obesity, severe dehydration, recent surgery or trauma)
Prophylactic dose of low molecular weight heparin (Enoxaparin): 0.5 mg/kg twice daily, till child is discharged from hospital
On suspicion of thrombosis, confirm by appropriate investigations and start on low molecular weight heparin in therapeutic doses for period of 12 weeks with monitoring
Children already on anticoagulation therapy may continue same unless they develop active bleeding
Children with asymptomatic infection or mild disease should receive routine childcare, appropriate vaccination (if eligible), nutrition counselling, and psychological support on follow up
In addition to above, for children with moderate to severe COVID, at discharge from hospital, parents/caregivers should be counselled regarding monitoring for persistence/worsening respiratory difficulty and explained the indications for bringing the child back to facility
Children who develop any organ specific dysfunction during hospital stay or subsequently should receive appropriate care