CHKD Treatment Guidance for COVID-19 in Children
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
CHKD Treatment Guidance for COVID-19 in Children
***This guideline will be frequently updated. Ensure you are utilizing the most recent version.***
Patient population: Patients with suspected or confirmed COVID-19 infection who are admitted to an inpatient floor or the intensive
care unit.
Key Points: Numerous studies suggest that COVID-19 disease manifestations are significantly less severe in children. However,
several reports exist that describe children with COVID-19 who required an intensive level of care.23
Clinical symptoms: Symptoms range from uncomplicated upper respiratory tract viral infection to pneumonia, acute respiratory
distress syndrome (ARDS), sepsis, and septic shock (Table 1). No specific data is available establishing risk factors for severe
COVID-19 disease in children.23
COVID-19 Treatment:
Supportive Therapy: Supportive treatment including sufficient fluid and calorie intake, and additional oxygen
supplementation should be used in the treatment of children infected with COVID-19. The aim is to prevent ARDS, organ
failure, and secondary nosocomial infections. If bacterial infection is suspected, broad-spectrum antibiotics may be used.22
NSAID use is not contraindicated and has not been proven to have any added benefit or adverse outcomes in patients with
COVID-19.
Antiviral Therapy: Currently no drug has been proven to be safe and effective for treating COVID-19. There is insufficient
data to recommend either for or against the use of any antiviral or immunomodulatory therapy in patients with COVID-19
who have mild, moderate, severe, or critical illness. Treatment should be considered as outline in (Figure 1). All agents
described in Table 4 are considered investigational or expanded access/EUA, and the decision to use should be made only
after weighing the risks and benefits in addition to clinical status, comorbidities, and interacting medications.22-23
Pre/Post-exposure prophylaxis: No drugs have been found to be effective and are not recommend by the COVID-19
Treatment Guidelines.23
Anticoagulation: COVID-19 is associated with an increased risk of venous thromboembolism (VTE) in adults. Due to this risk,
routine use of pharmacologic prophylaxis or therapeutic anticoagulation is utilized unless contraindicated. Currently there are no
specific recommendations for pediatric patients with COVID-19.15-21 Pediatric confirmed COVID-19 hospitalized patients should be
assessed based on risk factors as outlined below:
1) Consider Hem/Onc consult for risk assessment and recommendations.
2) Individual VTE risk factors should be evaluated on admission and reassessed every 48-72 hours for the duration of the
hospitalization.
3) Enoxaparin prophylaxis is recommended in adult patients with confirmed COVID-19 unless contraindicated.
4) Enoxaparin prophylaxis should be strongly considered in pediatric patients with confirmed COVID-19 unless
contraindicated.
5) An assessment of bleeding risks verses benefit should be completed on each patient (Table 3).
6) Alternative methods of prophylaxis such as early ambulation or mechanical prophylaxis should be considered in
contraindicated patients and all COVID-19 pediatric patients, if applicable. 15-21
Due to increased demand and drug shortages, hydroxychloroquine now requires ID approval prior to administration to
ensure our supply is utilized to the most at-risk patients.
If an order for hydroxychloroquine is entered it will NOT be verified by a pharmacist until ID approval is confirmed and
documented.
ID should be paged to obtain approval by the ordering provider once a patient is identified and meets the requirements for
treatment, see (Figure 1).
Documentation of approval may occur via:
o Verbal confirmation of ID attending approval, date, and time, from the ordering provider.
o Direct confirmation of approval from the ID attending to the pharmacist.
If ID approval is not obtained or is rejected, hydroxychloroquine cannot be verified or dispensed.
The pharmacists will document the approving ID attending, date, and time on the active order.
Version 1.5-May 4, 2020Table 1. Clinical symptoms associated with COVID-19 infection
Symptoms Description
Uncomplicated upper respiratory tract viral infection with nonspecific symptoms including:
Uncomplicated Illness Fever, cough, sore throat, nasal congestion, malaise, headache, muscle pain
Without signs of dehydration, sepsis, or shortness of breath
Non-severe pneumonia presenting with cough or difficulty breathing +tachypnea
Mild Pneumonia
Without signs of severe pneumonia
Adolescent: fever or suspected respiratory infection + one of the below:
RR > 30 breaths/min
Severe respiratory distress
SpO2 < 90% on room air
Severe Pneumonia
Child: cough of difficulty breathing + one of the below:
Diagnosis is clinical
Central cyanosis
SpO2 < 90%
Severe respiratory distress
Clinical signs of pneumonia + inability to breast feed or drink, lethargy, convulsions
New or worsening respiratory symptoms within one week of known clinical insult
ARDS Chest imaging consistent with ARDS
Respiratory failure not explained by cardiac failure or fluid overload
Sepsis Diagnosis made clinically
Septic Shock Diagnosis made clinically
Source: World Health Organization
Table 2. Criteria for risk high-risk of cytokine storm10
1 or more of the below Description
Serum IL-6 ≥3x upper normal limit
Ferritin >300 ug/L with doubling in 24 hrs
Ferritin + >600 ug/L at presentation
LDH >250
D-dimer Elevated
Table 3. Bleeding Risk Factors: 15-21
Bleeding Risk Factors Description
Intracranial hemorrhage
Not Recommended
Active bleed
Intracranial mass
Lumbar puncture w/in 24 hours
Consider with caution
Coagulopathy
Neurosurgical procedure w/in 24 hours
Version 1.5-May 4, 2020Figure 1. Treatment Algorithm in Children: Dosing per Table 4
Outpatient
Otherwise healthy child with Awaiting COVID19 results Supportive Care
suspected COVID19 ONLY
Including high risk*
Supportive Care
Confirmed (+) COVID19 test
ONLY
Inpatient: Non-ICU
Otherwise healthy child with suspected
COVID19 + clinical symptoms including: Awaiting COVID19 results Supportive Care
Uncomplicated illness ONLY
Mild pneumonia
Confirmed (+) COVID19 test Supportive Care
ONLY
Inpatient Non-ICU: High Risk*
COVID19 + clinical symptoms including: Supportive Care +
Awaiting COVID19 results
Mild pneumonia Consider Hydroxychloroquine
Consider baseline and daily interleukin levels
Supportive Care +
Confirmed (+) COVID19 test
Consider Hydroxychloroquine
Inpatient (PICU/NICU)
COVID19 + clinical symptoms including:
Severe pneumonia Supportive Care +
Awaiting COVID19 results
ARDS Consider Hydroxychloroquine
Sepsis/septic shock
Consider baseline and daily interleukin levels
Confirmed (+) COVID19 test
Mechanically Ventilated NOT Mechanically Ventilated
Evaluate Remdesivir Eligibility:
Refer to CHKD Remdesivir policy High risk of severe disease Supportive Care +
Policy located on COVID-19 kdnet + Hydroxychloroquine
∆
If eligible, Consult ID ASAP to initiate process High risk of cytokine storm (+/-) Azithromycin
OR
Rapidly worsening gas exchange
+
Pulmonary infiltrates
Remdesivir Approved Remdesivir Exclusion +
SpO2 ≤ 93% on RA or > 6L/min
Supportive Care +
Redesivir Ψ Supportive Care +
Hydroxychloroquine + Hydroxychloroquine +
∆
Consider Tocilizumab Consider Tocilizumab ∆
(+/-) Azithromycin
* High Risk- Immunocompromised, cardiovascular, pulmonary, hepatic, renal, hematologic, neurologic conditions
∆
See Table 2
Ψ
Shipment requires 1-3 days
Version
Consider QTc1.5-May 4, 2020
prolongation risk with combo therapy (Figure 2)Table 4. Agents under investigation for treatment of COVID-19:
1st Line Antiviral therapy Dosing & Duration Comments
Hydroxychloroquine Adult dosing (≥18 years): Adverse events:
(PO only) 400mg BID x 2 doses (load) day 1, then 200 mg BID Retinopathy rash, nausea, glucose
days 2-5 fluctuations, and diarrhea. GI symptoms
Empiric therapy for high risk & May be mitigated by taking with food
critical patients Pediatric dosing9 ( 50Adult 400mg BID 200 mg BID May start while awaiting G6PD results
LD-Loading Dose
Follow QT evaluation (Figure MD-Maintenance Dose Additional Comments:
2) if combination therapy Suspension may be given via NG tube
Duration: Separate from antacids by at least 4 hours
Infectious Disease Restricted 5 days May be crushed
Extended ventilation or profound immunosuppression Fetal ocular toxicity in animal studies
duration may be extended Excreted into breast milk
Tocilizumab Adult Dosing (≥18 years): Tocilizumab adjunctive therapy may improve
50-59 kg: 400 mg IV oxygenation & time to symptom resolution in
Consider adding to antiviral 60-85 kg: 600 mg IV high risk patients with cytokine storm
therapy for patients meeting >85 kg: 800 mg IV
criteria (Figure 1) Contraindications:
Pediatric Dosing (Azithromycin Pediatric dosing (
8. Gautret et al. (2020) Hydroxychloroquine and azithromycin as a treatment of COVID‐19: results of an open‐label non‐
randomized clinical trial. International Journal of Antimicrobial Agents – In Press 17 March 2020
DOI: 10.1016/j.ijantimicag.2020.105949
9. Michael Cohen-Wolkowiez, MD PhD; Anil Maharaj, PhD; Huali Wu, PhD, et al. Pediatric Trials Network (PTN)
Hydroxychloroquine Pediatric Dosing Guidelines to Target Treatment of SARS-CoV-2 Virus. 20 March, 2020
10. Giwa AL, Desai A, Duca A. Novel 2019 coronavirus SARS-CoV-2 (COVID-19): An updated overview for emergency
clinicians. Emerg Med Pract. 2020 May 1;22(5):1-28. Epub 2020 Mar 24
11. Chen C, Zhang XR, Ju ZY, et al. Advances in the research of cytokine storm mechanism induced by corona virus disease
2019 and the corresponding Go to www.ebmedicine.net/COVID-19 for updates to this article, podcasts and videos, and more
immunotherapies. Zhonghua Shao Shang Za Zhi 2020;36:E005-E005 (Basic science review)
12. Yonggang Zhou BF, Xiaohu Zheng et al. Pathogenic T cells and inflammatory monocytes incite inflammatory storm in
severe COVID-19 patients. 2020
13. Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. The
Lancet
14. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China:
a retrospective cohort study. Lancet (London, England) 2020:S0140-6736(0120)30566-30563 (Retrospective cohort study;
191 patients)
15. Meier KA, Clark E, Tarango C, Chima RS, Shaughnessy E. Venous thromboembolism in hospitalized adolescents: an
approach to risk assessment and prophylaxis. Hospital pediatrics. 2015;5(1):44-51
16. Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging
issues. Journal of thrombosis and haemostasis : JTH. 2018;16(2):196-208
17. Mahajerin A, Webber EC, Morris J, Taylor K, Saysana M. Development and Implementation Results of a Venous
Thromboembolism Prophylaxis Guideline in a Tertiary Care Pediatric Hospital. Hospital pediatrics. 2015;5(12):630-636
18. Hanson SJ, Punzalan RC, Arca MJ, et al. Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in
reducing the incidence of venous thromboembolism in critically ill children after trauma. The journal of trauma and acute
care surgery. 2012;72(5):1292-1297
19. Faustino EV, Raffini LJ. Prevention of Hospital-Acquired Venous Thromboembolism in Children: A Review of Published
Guidelines. Frontiers in pediatrics. 2017;5:9
20. Kim SJ, Sabharwal S. Risk factors for venous thromboembolism in hospitalized children and adolescents: a systemic review
and pooled analysis. Journal of pediatric orthopedics Part B. 2014;23(4):389-393
21. Parasuraman S., Goldhaber S. Venous Thromboembolism in Children. Circulation. 2006;113:e12-e16
22. Zimmerman P., Curtis N. Coronavirus Infections in Children Including COVID-19: An Overview of the Epidemiology,
Clinical Features, Diagnosis, Treatment and Prevention Options in Children. Pediatr Infect Dis J. 2020;XX:00–00
23. Panel on COVID-19 Treatment. COVID-19 Treatment Guidelines. Available at
https://www.covid19treatmentguidelines.nih.gov/overview/ Accessed (5/2020)
Infectious Disease Approval: 3/20/2020 Created by: Sarah Parsons Pharm.D., BCPPS & Laura Sass M.D.
Originated: 03/20/2020 Last Revised: 05/04/2020
Revision History:03/23/20 14:45
03/30/20: updated Lopinavir/ritonavir dosing and duration, remove azithromycin from combination early initiation, added QT
monitoring recommendations and risks, NSAID statement
4/3/20: Remdesivir reference to guideline, included reference for cytokine storm
4/9/20: NG administration for hydroxychloroquine, Remdesivir added to figure 1, azithromycin changed to (+/-) in figure 1. Tables
renumbered for organization, VTE prophylaxis guidance-Reviewed by Eric Lowe MD & Jessica Price PharmD
5/4/20: Updated information on disease process in children, added EUA to remdesivir, changed to consider hydroxychloroquine to
the treatment algorithm. Added new references. Removed Lopinavir-Ritonavir
The recommendations in this guide are meant to serve as treatment guidelines for use at The Children’s Hospital of The King’s
Daughters. As a result of ongoing research, practice guidelines may change from time to time. The authors of these guidelines have
made all attempts to ensure the accuracy based on current information; however, due to ongoing research, users of these guidelines are
strongly encouraged to confirm the information through an independent source.
Version 1.5-May 4, 2020You can also read
