See also

Bronchiolitis
Community acquired pneumonia
Croup

PIMS-TS (see Additional notes below)

Key points

1. Children are less severely affected by COVID-19 than adults, including those infected with newer variants such as the Delta strain
2. Appropriate respiratory support should be provided for any child with suspected or confirmed COVID-19
   
3. For children requiring high-flow oxygen or nebulised therapy, airborne precautions must be maintained and management must occur in the highest level of isolation available
   
4. COVID-19 may be an incidental finding in a child who presents with a different illness. Assessment and treatment should prioritise the child’s presenting clinical syndrome 

Background

• Coronaviruses, including SARS-CoV-2 (causing COVID-19) are a large family of viruses that cause respiratory infections
• Like other viruses, SARS-CoV-2 continues to evolve, with newer strains becoming more dominant due to increased transmissibility
  
• While the illness is usually mild in children, the COVID-19 pandemic is significantly impacting children’s social and emotional welfare through long periods of social isolation, loss of face-to-face education and separation from parents or carers unwell with the disease
  

Assessment

Place child in the highest level of isolation possible, ideally in a single room, with negative pressure if available

History

The full clinical spectrum of disease remains broad. Typical symptoms include:

• General features
  • Fever
  • Headache
  • Lethargy
• Respiratory symptoms
  • Cough
  • Sore throat
  • Coryza
• Gastrointestinal features
  • Vomiting
  • Diarrhoea
  • Abdominal pain

Risk factors for more severe disease

• Immunosuppression
• Children with severe or complex chronic disease
• Obesity
• Pregnancy
• Age
  • Less than 3 months corrected age
  • Adolescents

Examination

Examination should focus on the child’s presenting problem, for example:

• Respiratory
  • Increased work of breathing/respiratory distress
  • Tachypnoea
  • Cyanosis
• Hydration status

Assessment of severity

Use standardised, age-specific vital sign charts to rapidly assess a child’s current clinical status

• Tachycardia or tachypnoea that persistently breach the early warning of pre-MET call limits should prompt escalation of care
• In other children, disease may be severe without derangement of vital signs. Consider also the stage and progression of the current illness

Signs of severe illness include:

• severe respiratory distress
• severe hypoxaemia or cyanosis
• marked tachycardia
• altered mental state

Management

Care of the child should prioritise their current clinical status and illness syndrome (See:  Bronchiolitis,  Croup,  Pneumonia, Gastroenteritis, Asthma, Sepsis, Chest pain)

• Children should be investigated and treated based on clinical appearance, presence of a localised infective focus and clinical syndrome (eg bronchiolitis)
• Maintain a low threshold for assessment of complications (eg myocarditis/chest pain, respiratory, neurological) and disease progression
• A positive SARS-CoV-2 test may be incidental to the underlying cause of the child’s presentation

Investigations

• All children who meet current testing criteria for COVID-19 should receive a swab (see COVID-19 swabbing)
  • Testing criteria and case definitions may differ in each State)
• For children who fit the testing criteria and who require admission, follow local infection control guidance for isolation
• Consider repeat testing if a child clinically deteriorates and clinical suspicion of COVID-19 remains high
• Children with croup and/or suspected upper airway obstruction should not be swabbed for COVID-19, until it is deemed safe to do so by a senior clinician
• Other investigations as per the clinical presentation, for example:
  • Prolonged fever see Febrile child
  • Chest pain see Chest pain
    

Treatment

Treatment should be provided for the child in an appropriate setting, eg hospitalisation, community based, specific health service. This varies by state and can vary by Local government area or health service, see local protocols:

• NSW
• QLD
• VIC
  

Mild to moderate disease 

• Decision to admit should be supported by clinical assessment (including risk factors), social and geographical factors, and phase of illness
• Should be managed as per clinical syndrome
• Confirmed COVID-positive cases should be looked after in the highest isolation area possible
• Airborne precautions should be observed for ALL HCWs
• Decision to admit should be supported by clinical assessment (including risk factors), social and geographical factors, and phase of illness

Severe disease

• Respiratory support as required
• High-flow nasal oxygen therapy may be used when needed, but with appropriate airborne precautions to reduce risk of aerosolisation. Discuss with senior clinician and consult ICU/Retrieval services
• Decisions about respiratory support during transfer should be discussed by the senior clinician and ICU/Retrieval services
• Nebulised adrenaline should be reserved for severe  croup, due to risk of aerosolisation
• Airborne precautions must be maintained if child requires high-flow oxygen, non-invasive ventilation or nebulised therapy. Provide these therapies if indicated
• Management must occur in the highest level of isolation available
• Additional disease-specific treatments should be considered in consultation with Infectious Diseases team (see below)

Additional treatments

Considered in children at very high risk, with moderate to severe disease, and/or those who meet criteria for PIMS-TS (see Additional notes below). Always consult Infectious Diseases or a senior clinician

• Corticosteroids 
  • Consider for children requiring ongoing supplemental oxygen (including mechanically ventilated patients)
  • Starting dose dexamethasone (IV or oral) 0.15 mg/kg/day (max dose 6 mg)
  • Inhaled steroids may considered in some children <12 years old
• Venous thromboembolism prophylaxis
  • For hospitalised children, refer to local thromboprophylaxis guidelines and consult haematology
• Intravenous immunoglobulin
  • Consider for children who meet criteria for PIMS-TS, see Additional notes below
• Other immunomodulatory agents (eg: anti IL-1, anti IL-6 or anti-TNF)
  • May be considered as a third-line option for children with PIMS-TS 
  • Most of these treatments are restricted and may only be accessed through consultation with specialist teams including Infectious Diseases
• Disease-modifying treatments that are currently NOT recommended
  • There is no evidence to support the use of vitamin D, ivermectin, hydroxychloroquine, colchicine or azithromycin
  • Research is ongoing into the use of antiviral medications in children with COVID-19

Other treatment considerations

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

Immunisation

• Several COVID vaccines are available for children eg Cominarty (Pfizer) vaccine and Spikevax (Moderna). See Australian recommendations
• Both vaccines require two doses, have been shown to generate strong immunity and have high efficacy against symptomatic COVID-19 in adolescents
• Common side effects to both vaccines include:
  • injection site pain
  • headache
  • fatigue
  • fever
    These occur usually within 3 to 4 days after mRNA vaccines, can occur after either dose, but more common following second dose
    
    
• Myocarditis and pericarditis
  • Myocarditis and pericarditis have both been associated with mRNA COVID-19 vaccines (Pfizer and Moderna)
  • Rare, higher incidence in adolescent males and after the 2^nd dose
  • Most cases occur within 7 days, but have been reported to occur up to 14 days after vaccination
  • While most cases of myocarditis and pericarditis are self-limiting, some children will require specialist input and admission to hospital
  • An adolescent who presents with chest pain, shortness of breath, palpitations, syncope or dizziness within 1 to 14 days of receiving an mRNA COVID-19 vaccine requires thorough evaluation. Specific guidance can be found here
  • Other causes of acute chest pain and syncope should also be considered

Any adverse events following COVID-19 vaccination should be reported

Consider consultation with local paediatric team when

 All suspected or confirmed cases of COVID-19 requiring respiratory or ongoing hydration support 

Refer to local protocols for specific health service advice

Consider consultation with ICU/Retrieval services

All children requiring escalating respiratory support 

Consider consultation with infectious diseases

All children with severe disease or ongoing respiratory support

All children who meet criteria for PIMS-TS (see Additional notes below)

Consider transfer when

Confirmed case with severe or worsening moderate disease, or requiring care beyond the capacity of the local health service

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

Consider discharge when

Suspected or confirmed cases who do not require hydration or respiratory support. See local protocols above

• These cases must remain in home isolation as per local health department recommendations 

Parent information

• Raising Children Network: Coronavirus and children in Australia
• COVID-19 and immunosuppressed patients
• COVID-19 Paediatrics and youth
• Translated resources
• Myocarditis, pericarditis and COVID-19 vaccines

Additional notes

Paediatric Inflammatory Multisystem Syndrome temporally associated with SARS-CoV-2 ( PIMS-TS )

Very rare but serious complication that occurs 2-6 weeks after infection with SARS-CoV-2. The initial infection may be asymptomatic

Assessment

• PIMS-TS should be considered in an unwell child who presents with fever (≥3 days), signs of shock, rash and abdominal pain
• Several features overlap with Kawasaki disease and toxic shock syndrome
• Other infectious causes of inflammation, including sepsis, should also be considered
• Diagnostic criteria can be found here
  

Management

• All suspected cases of PIMS-TS should be discussed urgently with a senior clinician
  • Transfer to a tertiary centre with intensive care support may be required
• In consultation with Infectious disease consider:
  • Corticosteroids, maybe given before, or in combination with IVIg
  • Intravenous immunoglobulin (IVIg)
  • Low-dose aspirin

Other clinical features and advice on how to manage children with suspected PIMS-TS can be found here 

Additional resources

Infection control

Recommended sequence for donning and removing PPE may differ - follow local recommendations

How to don and fit N95 masks

New South Wales

How to don and remove PPE

PPE for Airborne Precautions

How to don and fit N95 masks videos

Queensland

How to don and remove PPE

Queensland Health PPE information video

Victoria

How to don and remove PPE

PPE for Airborne Precautions (video 1 below)

P2/N95 masks (video 2 below) 

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

PPE for Airborne Precautions

P2 and N95 masks

Last updated September 2021