COVID-19: Paediatric patients with suspected or confirmed case

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

These guidelines are based on the current available knowledge of the transmission of coronaviruses and may change as more evidence becomes available specifically regarding COVID-19.

This document has been developed primarily for use by staff within the Child and Adolescent Health Service (CAHS). For non-CAHS practitioners these should be used in combination with their own health service guidance advice.

Read the full PCH Emergency Department disclaimer.

Key points

  • The majority of children with COVID-19 have a mild illness which is indistinguishable from other common endemic viral illnesses e.g. rhinovirus, respiratory syncytial virus (RSV), influenza
  • Currently (and for the near future), the vast majority of presentations with acute respiratory tract infections in children will not be related to SARS-CoV-2 and will continue to follow the pattern of common paediatric illnesses
  • Pre-existing treatment protocols and guidelines for common paediatric conditions such as bronchiolitis, viral wheeze/asthma and lobar pneumonias should be followed, with modifications to reduce the use of aerosol generating procedures (AGPs) such as nebuliser therapy and high flow nasal oxygen
  • If AGPs are required, standard, contact and airborne precautions are indicated, including the use of a N95 mask.

Case defintions

Patients (or clients in the community setting) who meet the following case definitions should be managed as a confirmed / suspected case. Any person who is tested for COVID-19 should be isolated until results are available.

Confirmed case

  • A person who tests positive to a validated specific SARS-CoV-2 nucleic acid test or has the virus identified by electron microscopy or viral culture

Suspect cases

Any person with:

‘Acute respiratory symptoms’ (cough and/or sore throat and/or shortness of breath)

OR

Fever ≥38°C (or history of fever in the last few days), where no other cause suspected/identified
  • No other cause suspected/identified’ refers to patients who have fever secondary to a clear cause (e.g.: urinary tract infection, appendicitis)
    • These patients do not necessarily require testing for COVID-19, particularly in the absence of co-existing acute respiratory symptoms
    • The decision not to test however is an important clinical judgement and should ideally be made by a senior clinician (suggest ED consultant or treating team consultant). The Clinical Microbiologist or Microbiology Registrar is also able to provide testing guidance where uncertainties exist

Epidemiology

There is minimal epidemiological data on children with COVID-19, however early data out of China1 and USA2 suggests:

  • Less than 2% of known cases are in children
    • The majority of children have mild disease
      • 5% develop an oxygen requirement
      • 0.5% have critical disease
  • Commonly described symptoms (>25% of cases)
    • fever, myalgia
    • cough, sore throat
    • headache
  • Less common symptoms (<25% of cases)
    • shortness of breath
    • nausea, vomiting, diarrhoea, abdominal pain
  • The presentation may differ from adults:
  • only 73% of paediatric cases have one of fever, cough or shortness of breath
    • fever present in only 50%
    • cough only seen in 50%
    • gastrointestinal symptoms less commonly seen
  • There is not yet clear evidence of paediatric subgroups that are at increased risk of severe disease although a cautious clinical approach should be taken when managing the following patients may be advisable:
    • children less than 1 year old
    • those with co-morbidities including pre-existing respiratory or cardiac disease, oncological condition or who are otherwise immunosuppressed children

Assessment

The goals of assessment are to
  • determine the likelihood of COVID-19
  • define the clinical syndrome e.g. URTI, wheezing illness, pneumonia
  • determine the severity of illness
  • determine the need for admission e.g. oxygen requirement, likelihood of deterioration, dehydration
  • determine the likelihood of needing an AGP either immediately or in the near future.

History

History should focus on:
  • respiratory symptoms
  • fever or history of fever
  • hydration and gastrointestinal symptoms
  • similar illness in contacts and family members
  • exposure to confirmed cases of COVID-19
  • travel history: interstate and international
  • comorbidities including respiratory or cardiac disease, immunosuppression, prematurity.

Examination

Examination should be focused and modified to reduce the exposure of staff to potential infection
  • minimise examination of the nose and oral cavity - only perform if a positive finding will alter management.
  • examine from the side or back to minimise exposure to direct coughing/sneezing
  • Examination should focus on:
  • respiratory: respiratory distress, wheeze, stridor
    • circulation
    • hydration assessmen
    • gastrointestinal signs
    • determining a source of fever.

Severity of illness

Suspect case

  • The majority of suspect cases will have an illness unrelated to COVID-19
  • Severity of illness is best assessed by:
    • first principles
      • end of bed assessment
      • observations/EDOES/Paediatric Early Warning Tool
      • respiratory exam
      • hydration
    • standard assessment of the clinical syndrome e.g. bronchiolitis, asthma, pneumonia
  • Suspect cases with hypoxia unrelated to wheeze, upper airway obstruction, lobar pneumonia or cyanotic congenital heart disease – assess severity as per the confirmed case criteria.

Confirmed case

  • The severity of disease in confirmed COVID-19 cases can be classified according to need for oxygen therapy and respiratory support
Mild
  • No supplemental oxygen requirement to maintain saturation > 92%, no or mildly increased work of breathing
Moderate
  • Oxygen requirement of < 8L/min via Hudson mask, < 4L via nasal prongs or head box < 50% oxygen to maintain target saturations of > 92%
Severe
  • Oxygen requirement exceeding above, or requiring high flow nasal oxygen to maintain target saturation of > 92%
Critical
  • Hypoxia despite the above measures. Potentially requiring intubation and ventilation to maintain oxygen saturations > 92%
  • Additional features may include circulatory shock, acute renal injury, encephalitis, myocarditis and secondary bacterial infection.

Investigations

A: Who to test

  • Test only suspect cases (as per definitions above)
    • If a patient has symptoms that do not fulfil the criteria, yet the clinician believes that COVID-19 testing is indicated, please discuss with on-call Clinical Microbiologist or Clinical Microbiology Registrar to consider approval of testing
    • WA Department of Health policy states that testing of asymptomatic patients in the setting of limited community transmission is only supported in the pre-operative workup of children undergoing aerodigestive tract surgery where prolonged exposure to aerosols is expected – “Identification and Use of Personal Protective Equipment in the Clinical Setting During the Coronavirus (COVID-19) Pandemic Policy

B: Nasopharyngeal specimen collection and transport

  • Clinicians must complete the pathology test form to include reason for testing and if patient is a known contact of a positive case of COVID-19. This will assist with prioritisation of testing
  • For hospitalised cases, additional respiratory virus testing is recommended and requested on the same pathology request form. The same swab can be used
  • Routine specimen collection is NOT considered an aerosol generating procedure (AGP) and collection should occur under droplet, contact and standard precautions
    • For a small number of patients the collection will be associated with an AGP (e.g.: mechanical ventilation, tracheostomy) and for these patients airborne, contact and standard precautions should apply
  • For further information see Figure 3 - ‘Transmission-based Precautions’ flowchart below
  • Use a single dry flocked swab for PCR testing:
    • The swab should be inserted once into the nasopharynx. This is a specific CAHS recommendation as multiple upper airway site sampling is potentially distressing for children without clear evidence of increased viral detection
    • Place swab in universal transport medium (UTM) and then into a single plastic specimen bag for transport to PathWest at QE11 (do not place in pneumatic transport tube)
    • Samples should be walked to the PathWest Central Reception Area, PP Block (no additional PPE is required for those delivering the swabs)
  • For further details, see HealthPoint PathWest (WA Health only).

Figure 1:

Flocked swab

Figure 2:

Collection technique

The following notification processes should occur at the time of specimen collection:

  • All patients from whom a sample is collected for COVID-19 PCR testing should be notified to the Department of Health as a “suspected case” using the online notification form
  • To prioritise testing of admitted patients it is recommended that the clinician:
    • documents that the child is being admitted to hospital along with other clinical details in the “Clinical Notes” section of the request form
    • for urgent cases (e.g. severely unwell or immunocompromised) makes a phone call to the Clinical Microbiology Registrar (in-hours) or Consultant (after hours) is recommended to ensure this prioritisation occurs

C: Other laboratory and medical imaging investigations

  • Laboratory (e.g. CRP, WCC, procalcitonin) and radiological findings (e.g. chest x ray, CT) are not specific nor sensitive enough to be of routine use. The role of these investigations is for detection of complications or excluding alternative diagnosis
  • Investigations suggested for suspected or confirmed COVID-19 cases:
    • Mild: Nil
    • Moderate: Consider chest x-ray to rule out lobar pneumonia, effusion, cavitation
    • Severe: Chest x-ray to rule out lobar pneumonia, effusion, cavitation. Consider blood gas, full blood picture (FBP), electrolytes/urea/creatinine (EUC) and liver function tests (LFTS)
    • Critical: Chest x-ray. Assessments of end organ function including blood gas/lactate, FBP, EUC, LFTs, coagulation profile

Management of confirmed/suspected COVID-19 patient

  • There are no proven treatments for COVID-19
  • Management is supportive (adequate oxygenation and hydration) whilst maintaining staff safety through appropriate use of transmission-based principles and rational use of AGPs

Infection control principles

  • In order to minimise transmission between patients, visitors and environmental surfaces and fellow Healthcare workers (HCWs) relevant Infection Prevention & Control (IP&C) precautions must be followed from the point of entry to the healthcare setting
  • The minimum IP&C measures for suspected or confirmed cases of COVID-19 are the application of droplet, contact and standard precautions for routine care. For specific patients such as those undergoing AGPs - airborne, contact and standard precautions are required
  • For detailed IP&C advice please refer to the following reference documents:
i. CAHS COVID 19 – Infection Control, Staff Health and Patient Flow guidelines
ii. Govt of WA Dept. of Health Policy: Coronavirus Disease -19 (COVID-19) Infection Prevention and Control in the Hospital Setting V6, 08 April 2020

Figure 3: Transmissions based precautions flowchart

Figure 3: Transmissions based precautions flowchart

Aerosol generating procedures (AGPs)

  • Prior to performing an AGP consider the need and optimal timing of the procedure
  • AGPs procedures promote the generation of fine airborne particles and include:
    • Tracheal intubation and extubation
    • Manual bag-valve mask (BVM) ventilation before intubation
    • Non-invasive ventilation including CPAP and ‘Neopuff’
    • Tracheotomy, tracheostomy change
    • Tracheal suction (without a closed system)
    • Bronchoscopy/bronchoalveolar lavage
    • Sputum induction & chest physiotherapy
    • Open suctioning of airways
    • High flow nasal oxygen
    • Nebulised medication
    • Cardiopulmonary resuscitation
    • Aerodigestive surgical procedures
    • Collection of respiratory specimens in severely symptomatic patients (ICU- level severity)
  • Note – the following are not considered AGPs: NGT insertion, nasopharyngeal sampling, low flow oxygen therapy and Nitrous Oxide administration for procedural sedation
  • Senior medical input should determine if the AGP is warranted based on clinical need. Decision making should be based on likely clinical benefit and whether an alternative exists (e.g. MDIs via dedicated single patient use spacer rather than nebuliser, IV therapy for asthma)
  • If an AGP is deemed essential in a child with an acute respiratory tract infection with a positive or unknown COVID-19 status
    • The procedure should be carried out in a negative pressure isolation room (NPIR) or single room with the door closed if NPIR not available
    • Attending staff must wear airborne PPE
    • Limit the number of healthcare workers who enter the room
    • PPE precautions should be retained for 30 minutes following the procedure (same duration for NPIR or single room)

Management based on clinical manifestation

Thresholds for admission/transfer of patients with acute respiratory illness currently should not change. These decisions should be based on the clinical severity of disease, not the presumed underlying viral aetiology

Management based on severity of illness

1. Mild

  • Children with mild disease may not require admission to hospital if respiratory and hydration status are stable and social circumstances permit discharge home
  • Manage children as per their clinical symptoms
  • Families of children with suspected COVID who are discharged from hospital must be provided with both verbal and written information advising the need to remain in isolation pending the result of their COVID swab and WA Health guidelines including when and how to seek medical care in care in the event of deterioration

2. Moderate

  • Children with moderate disease should be admitted to hospital
Respiratory support
  • The following methods of oxygen delivery should target SpO2 of > 92%
    • Low flow nasal prong oxygen, maximums:
      • 2.5L/min infant
      • 3L/min child
      • 4L/min adolescent
    • Hudson mask to maximum 8L/min
    • Head box oxygen, if FiO2 > 0.5 is required consider patient as severe

3. Severe

  • Children with severe disease should be admitted to hospital and discussed with both the admitting consultant and PCC
Respiratory Support

  • The following methods of oxygen delivery should target SpO2 of > 92%
  • Non-rebreather mask 10-15L/min
  • Humidified high flow nasal oxygen (HHFNO) is an AGP. The decision to commence a child on HHFNO must be made in conjunction with a Consultant (ED, general paediatrics, respiratory medicine, intensive care). Use of HHFNO use should be limited to the management of hypoxic respiratory disease that is not manageable with standard intranasal or mask oxygen. Work of breathing alone is not an indication for its use

4. Critical Illness

  • Increase inspired oxygen concentration as required by headbox, HHFNO
  • Manage primary pathophysiology i.e. upper airway obstruction, asthma whilst minimising AGPs
  • If satisfactory oxygenation (SpO2>92%) cannot be maintained consider risk/benefit of intubation and ventilation. This should be discussed with a PCH PCC consultant and/or a PCH anaesthetist
  • Refer to Consensus statement Safe Airway Society – Principles of airway management and tracheal intubation
    • These principles apply to the paediatric population
  • Intubation is an AGP and should be undertaken by a team that includes the most skilled intubater available. The anaesthetic technique should minimise risk to patient and staff including, pre-oxygenation, turning off oxygen flow prior to mask removal, rapid sequence induction, two handed approach to BVM ventilation to minimise droplet dispersal, use of videolaryngoscopy (e.g. C-Mac), cuffed ETT and placing of viral filter between the mask/ETT and self-inflating bag
  • ETT suction should be minimised but may be essential. It should be performed with in-line suction apparatus incorporated into the airway circuit at the time of intubation
Cardiopulmonary Resuscitation
  • Clinical staff should don appropriate airborne PPE prior to commencing resuscitation efforts, irrespective of the patient’s condition
  • Additional precautions should include:
    • two hand mask technique when using BVM
    • a viral filter used in the circuit between mask or ETT and self-inflating bag
    • cessation of CPR during intubation to minimise delays
  • For further guidance recommend referring to the ALPS guideline for Paediatric Advanced Life Support (with COVID-19 considerations)

Figure 4: Flowchart of management by illness severity

Flowchart of management by illness severity

Other treatment

  • Currently there are no evidence based recommended treatments for COVID-19 illness that can be recommended. Trials are under way to assess effectiveness and safety of numerous therapies
  • Novel therapies (such as chloroquine, remdesivir, anti-HIV therapies) should only be used in consultation with an Infectious Diseases Physician
  • Hydration should be maintained by oral, NG or IV routes using standard guidelines
  • Routine nasal suctioning is not recommended
  • Ibuprofen
    • Some case reports have suggested that patients with COVID-19 administered ibuprofen have had more severe outcomes.
    • Due to the paucity of evidence in this area, major guidelines (WHO, NICE) have taken different positions on recommending ibuprofen in patients with COVID-19. As this medication is only for symptomatic management and a safe alternative exists, paracetamol should be used preferentially

Special group

  • Patients with a chronic disease who present with an acute respiratory tract infection should be discussed with their primary paediatric consultant

Oncology

  • There is a dedicated Oncology and Haematology COVID-19 advice line phone for families and carers with questions and concerns about their child and Coronavirus. Call 0436 595 810 between the hours of 8.00am – 6pm, Monday to Friday. After these hours call Ward 1A on 6456 3517
  • Health professionals should continue to contact the on-call Oncologist or Haematologist for all clinical advice

Palliative Care

  • Resources are available on HealthPoint (WA Health only) for clinicians including guidance on ‘Goals of Care Planning’ pre-transfer to PCH as well as planning discussions with families.

Transfer of children to and from PCH

Thresholds for the transfer of patients with acute respiratory illness to PCH should not change. Decisions will continue to be based on the clinical severity of disease. Clinical advice relating to patient management should be sought as usual from the PCH Paediatric Critical Care consultant or paediatric specialist
  • To proceed with a transfer of a child to PCH, the referring team are required to contact the Patient Flow Command Centre between the hours of 0800 – 17000hrs (Monday – Friday) on 9222 4468
    • Outside of business hours and at weekends, urgent/priority 1 transfers to proceed through usual transfer mechanisms
  • In general, children being managed at PCH who are confirmed to have COVID-19 (or who are still awaiting their result) will not be transferred back to their local hospital. Transfer back to the local hospital may be appropriate in some situations, but this must be agreed at a Consultant to Consultant level

Test resulting

Confirmed COVID-19 positive cases

  • If a child tests positive it is the responsibility of the treating team to contact the family to inform them of the positive result. Parents should be advised to seek further medical attention if their child’s symptoms worsen. Consider scheduling a telephone or telehealth review
  • The treating team do not need to notify the Public Health Emergency Operations Centre (PHEOC) as long as the initial notification was made at the time of testing. PathWest will take responsibility for contacting PHEOC who will contact the family to arrange contact tracing and provide further guidance on length of social isolation

Confirmed COVID-19 negative cases

  • If a child tests negative, families will receive an automated text message informing them of the result. The treating team do not need to contact the family.

Caregiver information

Allowed carers of inpatients should have a mask supplied appropriate to the transmission-based precautions of the room and be educated on hand hygiene (WA Health only), respiratory hygiene and cough etiquette. Carer are to remain in patient room except when coming and leaving the premises. Any other movement around the hospital should be discouraged and any requests must be discussed with the clinical nurse unit manager (in hours) or hospital nurse manager (out of hours). Carers who are in areas with limited in-room facilities (e.g. PCC) may leave the room for specific purposes such as toileting although the carer must wear a surgical mask, engage in appropriate hand hygiene practices and not walk around other parts of the hospital. A carer information sheet is available and should be given to families with suspected or confirmed COVID-19.

Families of all children with suspected COVID-19 who are discharged from hospital must be advised to remain in isolation pending the result of their COVID-19 swab. Families should be given an information sheet on the need to self-isolate.

References

  1. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics. 2020;145(6):e20200702
  2. CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children – United States February 12 – April 02, 2020. Morbidity and Mortality Weekly Report. April 06 2020.

Resources

Authors

The following people have contributed to the development of the guideline:
  • Michael Baker, Co-HOD Emergency Department PCH
  • Christopher Blyth, HOD Infectious Diseases PCH
  • Asha Bowen, Acting HOD Infectious Diseases PCH
  • Elizabeth Croston, PICU Specialist PCH
  • Dennis Chow, Co-HOD Emergency Department PCH
  • Briony Hazelton, Infectious Disease Physician/Microbiologist PCH
  • Geoff Knight, HOD Paediatric Critical Care PCH
  • Martyn Lethbridge, HOD Anaesthetics PCH
  • Andrew Martin, HOD Department of General Paediatrics PCH
  • Matthew O’Brien, Infectious Diseases Physician PCH
  • Janine Spencer, HOD Paediatric Services FSH
  • Desiree Silva, HOD Paediatric Services JHC
  • Andrew Wilson, HOD Respiratory Medicine PCH
  • Simon Wood, Executive Director Medical Services PCH

Endorsed by: CAHS  Date:  29 April 2020


 Review date: 


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