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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 7  |  Page : 31-35

Management of COVID-19-positive asymptomatic and mildly symptomatic children


Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India

Date of Submission23-Apr-2020
Date of Decision05-May-2020
Date of Acceptance13-May-2020
Date of Web Publication29-May-2020

Correspondence Address:
Dr. Pooja Gujjal Chebbi
Department of Pediatric Medicine, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPCC.JPCC_70_20

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  Abstract 

Coronavirus disease (COVID) in children is milder in comparison to adults with a better prognosis and minimal mortality. The most common clinical presentation of COVID-19 in children includes fever and cough, but a significant number of infected children may be asymptomatic contributing to transmission of the disease. Several hypotheses have been put forth to explain the less severe disease in children including lower expression of angiotensin converting enzyme 2 (ACE2) receptors in the lungs of pediatric patients which is the main receptor through which the virus enters the cells in the lung and mediates its effects, lower exposure to virions, higher likelihood of viral co-infection in children which may be responsible for limited replication of the severe acute respiratory syndrome coronavirus 2 by direct virus-to-virus interaction and competition and the protective role of Bacillus Calmette-Guerin vaccine. Reverse transcriptase-polymerase chain reaction testing of upper or lower respiratory tract secretions is the recommended confirmatory test and management is guided by the severity of illness in the child. In this review, we will discuss the management of asymptomatic and mildly symptomatic children.

Keywords: Asymptomatic, children, COVID-19, mildly symptomatic


How to cite this article:
Basavaraja G V, Sanjay K S, Keshavamurthy M L, Rajashekar Murthy G R, Chebbi PG. Management of COVID-19-positive asymptomatic and mildly symptomatic children. J Pediatr Crit Care 2020;7, Suppl S1:31-5

How to cite this URL:
Basavaraja G V, Sanjay K S, Keshavamurthy M L, Rajashekar Murthy G R, Chebbi PG. Management of COVID-19-positive asymptomatic and mildly symptomatic children. J Pediatr Crit Care [serial online] 2020 [cited 2020 Aug 8];7, Suppl S1:31-5. Available from: http://www.jpcc.org.in/text.asp?2020/7/7/31/285378




  Introduction Top


With its origin in Wuhan, China coronavirus disease-19 (COVID-19) has now become a global pandemic, with over 16,000 cases reported in India as per latest resources.[1] Although the disease affects all age groups, the pediatric population is less susceptible, with children constituting only about 1%–5%[2],[3] of diagnosed cases of COVID-19. The majority of these cases, in children younger than 18 (about 90%) were reported to have occurred through household transmission and about 10% were acquired through travel. Data from pediatric cases of COVID-19 not only show milder symptoms among children compared with adults,[2],[4],[5],[6] it also shows minimal mortality, which is reflected by the fact that though case Fatality Rate for this illness across all age groups has been reported between 2.3% and 9.8% from various countries, only a handful of deaths have been reported in the pediatric age group. Keeping the above information in mind majority of the pediatric patients who will be reporting to health care facilities will be either asymptomatic or mildly symptomatic and hence we write this review to guide the management of this group of patients.


  Pathogenesis Top


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus utilizes ACE2 receptors as its cell surface receptor, which is highly expressed by ciliated epithelial cells in the human lungs and allows the virus to attach to the cell.[7] The receptor is also expressed in the intestines, which explains the gastrointestinal symptoms that commonly occur in the early stage of the illness. The fact that cells in children's lungs express this receptor less than those in adult lungs may be one of the plausible explanations as to why the infection affects children less severely. The other possible theories why the disease is less severe in children include lower exposure to virions, being isolated at home with minimal exposure to environmental pollutants, higher likelihood of viral co-infection in children which may be responsible for limited replication of the SARS-CoV-2 by direct virus-to-virus interaction and competition[8] and the protective role of Bacillus Calmette-Guerin vaccine in which has been associated with heterologous immunity to other pathogens, potentially by a phenomenon called “trained immunity” involving innate cells such as macrophages, monocytes, and epithelia.[9]


  Clinical Course Top


The incubation period for COVID-19 is thought to extend to 14 days, with a median time of 4–5 days from exposure to symptoms onset.[10],[11],[12] Of those who are infected the median age group was 6.7 years (range-newborn to 15 years)[5] with no age or sex preponderance.[4] [Table 1] shows the age distribution of COVID-19 positive cases in the USA. 13%–15% of children who have tested positive for COVID-19 may be asymptomatic.[4],[5] Fever and cough are the most common symptoms observed in children.[4],[5] Other clinical features include sore throat, rhinorrhea, sneezing, myalgia, fatigue, diarrhea, and vomiting. Upper respiratory symptoms are more likely in children than lower respiratory symptoms, and appear to recover in 1–2 weeks. A small proportion of children may develop severe symptoms with respiratory distress and hypoxia and very few may progress respiratory failure, shock, and multiorgan dysfunction.
Table 1: Age distribution of COVID-19 Positive cases in the USA

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Atypical presentation is seen in children with medical comorbidities and may have delayed presentation of fever and respiratory symptoms. Medical conditions, which can increase the risk of severe disease, include:[13]

  • Blood disorders (e.g. sickle cell disease, use of blood thinners)
  • Chronic kidney disease undergoing dialysis
  • Chronic liver disease (e.g. chronic hepatitis)
  • Endocrine disorders (e.g. diabetes mellitus)
  • Severe obesity (body mass index ≥40 kg/m2).



  Clinical Categories Associated With Covid-19 Infection Top


Data available from most pediatric studies that have categorized patients into asymptomatic, mild, moderate, severe, and critical based on their clinical presentation laboratory findings, and chest imaging. In one large study,[4] patients with a confirmed SARS-CoV-2 infection (via identification of RNA) were categorized as:

  • Asymptomatic patients – 13%
  • Patients with mild symptoms (upper respiratory tract infection) – 43%
  • Patients with moderate symptoms (Pneumonia) – 40.9%
  • Patients with severe symptoms (With hypoxia –spo2 <92%) – 2.5%
  • Critical patients (respiratory failure, shock, or multi-organ system dysfunction): 0.4%.


As is evident from the above figures, pediatric COVID-19 patients may not have fever or cough. This emphasizes the need for social distancing and everyday preventive behaviors for all age groups because patients with less serious illness and those without symptoms are likely play an important role in disease transmission.


  Management Top


As per recent guidelines by the MOHFW and WHO, all children who test positive for COVID-19 whether symptomatic or asymptomatic must be managed in a health-care facility. In this review we will be discussing the management of asymptomatic and mildly symptomatic children. Although in the initial phase of the transmission of disease in our country it may be possible to accommodate these children in a health-care facility as per current recommendations but as the number of cases rise rapidly the same may not be possible in the near future and the current guidelines may have to be modified so that the health-care facilities are not overwhelmed, and resources can be most effectively utilized to cater to the needs of sick children. With this in mind, we will be discussing both hospital-based management as well as home-based care in these children.

Mild illness includes uncomplicated upper respiratory tract viral infection symptoms such as fever, fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion, or headache. Rarely, children may also present with diarrhea, nausea, and vomiting.[14]

Hospital-based care – taking care of the patient

Managing asymptomatic children positive for COVID-19 in a health-care facility

The isolation facility[15]

  • At triage give the patient a triple layer surgical mask and direct patient to separate single room if possible, or an isolation room with beds with adequate spatial separation between them (at least 1 m)
  • To create a 10-bed facility, a minimum space of 2000 sq. feet area clearlysegregated from other patient care areas is required
  • The room should be adequately ventilated. If room is air-conditioned, ensure 12 air changes/hour and filtering of exhaust air. A negative pressure in isolation rooms is desirable for patients requiring aerosolization procedures (intubation, suction nebulization). These rooms may have standalone air-conditioning. These areas should not be a part of the central air-conditioning
  • The room should have provision for separate entry and exit points and should not be co-located with postsurgical wards/dialysis unit/special new born care unit
  • It should have an attached bathroom and toilet facility to minimize patient and attender movement outside the isolation facility
  • The access to isolation ward should be through dedicated lift/guarded stairs
  • There should be a separate area for donning and doffing of personal protective equipment (PPE) for the health-care workers
  • The room should be equipped with a portable X-ray machine and a side lab so that movement of the patient is minimized preventing exposure to other individuals in the hospital
  • The furniture in the room should be minimal and easy to clean
  • The room should be equipped with a television and Wi-Fi if possible to keep the patients and their attenders occupied
  • Adequate arrangements should be made to ensure timely supply of food snacks water and other day-to-day needs of the patients and their attenders.


Infection prevention and control measures[14]

  • Instruct all children to cover nose and mouth during coughing or sneezing with tissue or flexed elbow for others and to perform hand hygiene after contact with respiratory secretions
  • Droplet and contact precautions prevent direct or indirect transmission from contact with contaminated surfaces or equipment (i.e., contact with contaminated oxygen tubing/interfaces)
  • If equipment needs to be shared among children, clean and disinfect between each patient or use disposable or dedicated equipment (e.g., stethoscopes, blood pressure cuffs, and thermometers)
  • Avoid contaminating environmental surfaces that are not directly related to patient care (e.g., door handles and light switches)
  • Avoid movement of children or transport. Perform hand hygiene.


Special situations

  • When isolated in a health-care facility if the caregiver and child are both positive for COVID-19 both should be made to wear N-95 masks to prevent transmission of infection to health-care personnel
  • When isolated in a health-care facility if the caregiver is negative and the child is positive, the child can be given an N-95 mask and the attender may be given full PPE and instructed to take proper infection prevention control measures including strict hand hygiene.


Management of a mildly symptomatic child[16]

  • Symptomatic treatment, bed rest, adequate hydration, and nutrition remain the cornerstone
  • Symptomatic treatment includes antipyretics, antihistaminic and cough syrups, and other medication depending on the patient's symptoms.


Antipyretics

  • Paracetamol is the first line antipyretic
  • Avoid ibuprofen in children with poor fluid intake or suspected acute kidney injury as there have been unsubstantiated reports of the drug being implicated in severe cases of COVID-19[17]
  • Nonsteroidal anti-inflammatory drugs should be avoided as it has been suggested that they might up regulate expression of ACE receptors in the lung
  • Requirement of ibuprofen for relief of fever may point toward significant inflammation, or be a sign of sepsis, and there should be a lower threshold for checking for blood inflammatory markers in these children
  • A health-care worker should regularly assess the child for worsening symptoms or presence of co-infection/illnesses
  • Children should be escalated to higher-level health-care unit in settings of clinical worsening.


Discharge policy

As per recent guidelines, all patients who test positive for COVID-19 will be discharged after viral clearance has been proven in respiratory samples through two specimens which test negative for Corona Virus by reverse transcriptase-polymerase chain reaction (PCR) within 24 h.

Home based care[18]

  • Home-based care can be considered, as long as they can be followed up and cared for by family members. This decision requires careful clinical judgment and should be informed by an assessment of the safety of the patient's home environment. In cases in which care is to be provided at home, if and where feasible, a trained health-care worker (HCW) should conduct an assessment to verify whether the residential setting is suitable for providing care; the HCW must assess whether the patient and the family are capable of adhering to the precautions that will be recommended as part of home care isolation (e.g., hand hygiene, respiratory hygiene, environmental cleaning, limitations on movement around or from the house).Children and household members should be educated about personal hygiene, basic infection prevention and control (IPC) measures, and how to care as safely as possible for the children having COVID19 to prevent the infection from spreading to household contacts. Counsel parents about signs and symptoms of worsening or serious COVID-19 in children. If they develop any of these symptoms, they should seek urgent care through feasible designated health facility.Although most children with mild disease may not have indications for hospitalization; it is necessary to implement appropriate IPC to contain and mitigate transmission.


Household members should adhere to the following recommendations:

  • Place the patient in a well-ventilated single room (i.e., with open windows and an open door)
  • Limit the movement of the patient in the house and minimize shared space. Ensure that shared spaces (e.g., Kitchen, bathroom) are well ventilated (keep windows open)
  • Household members should stay in a different room or, if that is not possible, maintain a distance of at least 1 meter from the ill person (e.g., sleep in a separate bed)
  • Limit the number of caregivers. Ideally, assign one person who is in good health and has no underlying chronic or immunocompromising conditions
  • Visitors should not be allowed until the patient has completely recovered and has no signs or symptoms of COVID-19
  • Perform hand hygiene after any type of contact with children or their immediate environment. Hand hygiene should also be performed before and after preparing food, before eating, after using the toilet, and whenever hands look dirty. If hands are not visibly dirty, an alcohol-based hand rub can be used. For visibly dirty hands, use soap and water
  • When washing hands with soap and water, it is preferable to use disposable paper towels to dry hands. If these are not available, use clean cloth towels and replace them frequently
  • To contain respiratory secretions, a medical mask should be provided to the patient and worn as much as possible, and changed daily. Individuals who cannot tolerate a medical mask should use rigorous respiratory hygiene; that is, the mouth and nose should be covered with a disposable paper tissue when coughing or sneezing. Materials used to cover the mouth and nose should be discarded or cleaned appropriately after use (e.g., wash handkerchiefs using regular soap or detergent and water)
  • Caregivers should wear a medical mask that covers their mouth and nose when in the same room as the patient. Masks should not be touched or handled during use. If the mask gets wet or dirty from secretions, it must be replaced immediately with a new clean, dry mask
  • Remove the mask using the appropriate technique, that is, do not touch the front, but instead untie it. Discard the mask immediately after use and perform hand hygiene
  • Avoid direct contact with body fluids, particularly oral or respiratory secretions, and stool. Use disposable gloves and a mask when providing oral or respiratory care and when handling stool, urine, and other waste. Perform hand hygiene before and after removing gloves and the mask
  • Do not reuse masks or gloves
  • Use dedicated linen and eating utensils for the patient; these items should be cleaned with soap and water after use and may be re-used instead of being discarded
  • Daily clean and disinfect surfaces that are frequently touched in the room where the patient is being cared for, such as bedside tables, bed frames, and other bedroom furniture. Regular household soap or detergent should be used first for cleaning, and then, after rinsing, regular household disinfectant containing 0.1% sodium hypochlorite (i.e. equivalent to 1000 ppm) should be applied
  • Clean and disinfect bathroom and toilet surfaces at least once daily. Regular household soap or detergent should be used first for cleaning, and then, after rinsing, regular household disinfectant containing 0.1% sodium hypochlorite should be applied
  • Clean the patient's clothes, bed linen, and bath and hand towels using regular laundry soap and water or machine wash at 60°C–90°C (140–194 °F) with common household detergent, and dry thoroughly. Place contaminated linen into a laundry bag. Do not shake soiled laundry and avoid contaminated materials coming into contact with skin and clothes
  • Gloves and protective clothing (e.g., plastic aprons) should be used when cleaning surfaces or handling clothing or linen soiled with body fluids. Depending on the context, either utility or single-use gloves can be used. After use, utility gloves should be cleaned with soap and water and decontaminated with 0.1% sodium hypochlorite solution. Single-use gloves (e.g., nitrile or latex) should be discarded after each use. Perform hand hygiene before putting on and after removing gloves
  • Gloves, masks, and other waste generated during home care should be placed into a waste bin with a lid in the patient's room before disposing of it as infectious waste. The onus of disposal of infectious waste resides with the local sanitary authority
  • Avoid other types of exposure to contaminated items from the patient's immediate environment (e.g., do not share toothbrushes, cigarettes, eating utensils, dishes, drinks, towels, washcloths, or bed linen)
  • When HCWs provide home care, they should perform a risk assessment to select the appropriate PPE and follow the recommendations for droplet and contact precautions
  • For mild laboratory confirmed children who are cared for at home, to be released from home isolation, cases must test negative using PCR testing twice from samples collected at least 24 h apart
  • Where testing is not possible, the WHO recommends that confirmed children remain isolated for an additional 2 weeks after symptoms resolve.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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