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COVID-19

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  • See also

    Bronchiolitis
    Community acquired pneumonia
    Croup

    Key Points

    1. Children appear to be less commonly and less severely affected by COVID-19 than adults
    2. Testing should be restricted to those who meet the current case definition* and those with severe disease requiring respiratory support
    3. Children with croup and/or suspected upper airway obstruction should not be swabbed until it is deemed safe to do so by a senior clinician
    4. The use of high-flow nasal oxygen and nebuliser therapy may aerosolise virus; use should be avoided if other options are effective
    5. Appropriate respiratory support should not be withheld. For children with suspected or confirmed COVID-19 requiring high-flow oxygen or nebulised therapy, airborne precautions (full PPE including N95 mask) must be maintained and management must occur in the highest level of isolation available. This should be discussed with a senior clinician and/or ICU. 

    *Case definitions may differ in each State: NSW Qld Vic

    Background

    • Coronaviruses are a large family of viruses that cause respiratory infections, including the common cold and more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS)
    • The most recently discovered coronavirus (SARS-CoV-2) causes coronavirus disease (COVID-19)

    Assessment

    Triage child to a single room, negative pressure if available

    History

    The full clinical spectrum of disease remains uncertain – case definitions are changing frequently. Typical symptoms include:

    • Fever
    • Cough
    • Sore throat

    Examination

    • Increased work of breathing/respiratory distress
    • Tachypnoea
    • Cyanosis

    Assessment of severity

    Management

    Investigations

    • Testing for coronavirus should be restricted to those who meet the current case definition including those with severe disease (*Case definitions may differ in each State: NSW Qld Vic)
    • For children with bronchiolitis, croup and pneumonia who don’t meet the case definition, testing should only be done for those with worsening disease who are likely to require escalation of respiratory support
    • PCR of throat and nasopharyngeal swab using same swab - tonsillar bed first, then nasopharynx (insert along the floor of the nasal cavity parallel to the palate about 1-2cm in until resistance is encountered, and rotate gently for 10-15 seconds; then withdraw and repeat the process in the other nostril
    • For patients who fit the testing criteria and who require admission, two negative nasopharyngeal swabs (plus a lower respiratory tract specimen such as sputum if possible) are recommended to exclude COVID-19 infection. Further testing can also be considered if a patient deteriorates and clinical suspicion of COVID-19 remains high
    • Children admitted to ICU should have a lower respiratory tract specimen collected
    • Chest x-ray is not routinely recommended and may be normal
    • CT has been used for diagnosis in adults; this is not recommended in children

    All confirmed cases must be notified to the Health Department (will assist with admission decisions or HITH follow up)

    Treatment

    Mild to moderate disease should be managed as per clinical syndrome (See Bronchiolitis, Croup, Pneumonia)

    • Confirmed COVID-positive cases should be isolated
    • Droplet and contact precautions (gloves, gown, surgical mask, eye wear) should be observed for ALL HCWs, family members and visitors
    • High-flow nasal oxygen therapy should be avoided if possible due to risk of aerosolisation – discuss with senior clinician and consider consultation with ICU
    • Nebulised adrenaline should be reserved for severe croup
    • Confirmed cases may not require admission if respiratory and hydration status are stable. Decision to admit should be supported by clinical assessment (including risk factors), social and geographical factors, and phase of illness
    • Consider Ambulatory/Hospital-in-the-Home (HITH) care if available

    Severe disease

    • Respiratory support as required
    • Airborne precautions (full PPE including N95 mask) must be maintained if child requires high-flow oxygen, non-invasive ventilation or nebulised therapy. Do not withhold these therapies if indicated
    • Management must occur in the highest level of isolation available
    • A number of antiviral and other medications have been suggested as possible treatments for severe COVID-19 - consult Infectious Diseases team

    Home-ventilated patients on CPAP or BiPAP and those with tracheostomy (with or without ventilation) who have suspected viral respiratory tract infection should be tested for coronavirus, and managed with airborne precautions until confirmed to be negative

    There is currently no evidence that ibuprofen can make COVID-19 worse.  There is insufficient evidence for ceasing any existing medication, including NSAIDs, immunosuppressants, angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs)

    Airborne precautions should be maintained for children with respiratory illness requiring nitrous oxide for procedures; staff involved should use PPE

    Infection Control
    How to don and fit N95 masks
    How to don and remove PPE

    Videos (see below)

    PPE for Droplet Precautions
    PPE for Airborne Precautions
    P2/N95 masks

    NSW Clinical Excellence Commission videos

    Queensland Health PPE information

    NB Care must be taken when removing PPE as contamination may occur

    Consider consultation with local paediatric team when:

    Suspected or confirmed cases of COVID-19 requiring respiratory support – consider consultation with respiratory medicine and/or ICU

    Consider transfer when:

    Confirmed case with severe or worsening moderate disease

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when:

    All suspected or confirmed cases who do not require respiratory support. These cases must remain in home isolation as per local health department recommendations 

    Parent information

    Coronavirus and children in Australia
    Translated resources
    COVID-19 and immunosuppressed patients

    Additional notes

    Health Department resources
    NSW Health information
    Queensland Health information
    Victorian DHHS information

    Other resources
    Paediatrics.Online
    Don’t Forget The Bubbles. An evidence summary of paediatric COVID-19 literature
    UpToDate
    RCH COVID-19 information (intranet only)

    PPE for Droplet Precautions

    PPE for Airborne Precautions

    P2 and N95 masks

    Last updated April 2020

  • Reference List

    1. Brewster D et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group. Medical Journal of Australia. 2020 Retrieved from URL https://www.mja.com.au/system/files/2020-03/Updated%20SAS%20COVID19%20consensus%20statement%2017%20March%202020.pdf
    2. Cai J et al. A Case Series of children with 2019 novel coronavirus infection: clinical and epidemiological features. Clinical Infectious Diseases. 2020. Retrieved from URL https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa198/5766430
    3. Dong Y et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics. 2020. Retrieved from URL https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0702.full.pdf
    4. Lu et al. SARS-CoV-2 Infection in Children. The New England Journal of Medicine. 2020. Retrieved from URL https://www.nejm.org/doi/full/10.1056/NEJMc2005073
    5. Zimmermann P et al. Coronavirus Infections in Children Including COVID-19. Pediatric Infectious Diseases Journal. 2020. Retrieved from URL https://journals.lww.com/pidj/Abstract/onlinefirst/Coronavirus_Infections_in_Children_Including.96251.aspx