Version July 2025
INTRODUCTION —
Coronavirus disease 2019 (COVID-19) illness is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical spectrum of COVID-19 ranges from asymptomatic infection to mild respiratory tract symptoms to severe pneumonia with acute respiratory distress syndrome and multiorgan dysfunction.
This topic will discuss the management of COVID-19 in children. The epidemiology and clinical features of COVID-19 that are specific to children, multisystem inflammatory syndrome in children, and COVID-19 in the peripartum period are discussed separately:
●(See "COVID-19: Clinical manifestations and diagnosis in children".)
●(See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management and outcome".)
●(See "COVID-19: Overview of pregnancy issues".)
●(See "COVID-19: Intrapartum and postpartum issues", section on 'Care of newborns of infected mothers'.)
GENERAL MANAGEMENT CONSIDERATIONS
Use of NSAIDs — Nonsteroidal anti-inflammatory drugs (NSAIDs) that are used chronically for other conditions may be continued unless there are other reasons for discontinuation (eg, gastrointestinal bleeding, kidney injury) [1,2]. Despite initial concerns about the safety of NSAIDs in patients with COVID-19 [3,4], in a meta-analysis of 11 observational studies (>683,000 participants), exposure to NSAIDs was not associated with increased risk of SARS-CoV-2 infection, severe/critical COVID-19 disease, or all-cause mortality [5].
Management of chronic medications
●Asthma medications – Considerations related to the safety of glucocorticoids and nebulized medications for children with asthma are discussed separately. (See "An overview of asthma management in children and adults", section on 'Immunizations and antiviral strategies'.)
●ACE inhibitors and angiotensin receptor blockers – Children receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should continue treatment with these agents if there is no other reason for discontinuation (eg, hypotension, acute kidney injury) [6]. This approach is supported by multiple guideline panels [7-11].
Although there has been speculation that patients with COVID-19 who are receiving ACE inhibitors or ARBs may be at increased risk for adverse outcomes, the hypothesis is not supported by findings from observational studies. (See "COVID-19: Issues related to acute kidney injury, glomerular disease, and hypertension", section on 'Renin angiotensin system inhibitors'.)
●Immunosuppressive therapy – For children receiving immunosuppressive therapy, we discuss the benefits and risks of reducing immunosuppressive therapy with the prescribing specialist (eg, oncologist, transplant clinician, rheumatologist, gastroenterologist). Although the relationship between immune compromise and severe COVID-19 disease has not been well established in children [12,13], management of some viral infections in immunocompromised hosts includes reduction of baseline immunosuppression, if reduction is possible [14,15]. Information about adjusting immunosuppressive therapy for specific conditions is presented separately. (See "COVID-19: Issues related to solid organ transplantation", section on 'Adjusting immunosuppression'.)
RISK STRATIFICATION
In children with COVID-19, risk stratification is employed to determine appropriate management in both outpatient and inpatient settings. Children may be considered at high risk for progression to severe COVID-19 illness if the following conditions are met:
●Moderately or severely immunocompromised (table 1)
Or
●Presence of high-risk condition, lack of up-to-date vaccination against COVID-19, and no COVID-19 infection in past four months, plus one of the following:
•≥1 high-risk condition that is severe or poorly controlled
•≥2 high-risk conditions
•<1 or ≥12 years of age
DETERMINE MANAGEMENT SETTING
●Indications for hospitalization – Most children with documented or suspected COVID-19 and mild symptoms (eg, fever, cough, pharyngitis, other respiratory symptoms) can be managed at home. Indications for hospitalization include:
•New or increased requirement for supplemental oxygen (table 2)
•Fever in infant younger than 30 days
•Multisystem inflammatory syndrome in children (see "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management and outcome", section on 'Management')
●Assessment of illness severity – We use the following tiered approach to categorize levels of COVID-19 illness severity (table 2) [16]:
•Tier 1: Mild illness – No new or increased supplemental oxygen requirement
•Tier 2: Moderate illness – New or increased requirement for supplemental oxygen via nasal cannula
•Tier 3: Severe illness – New or increased requirement for supplemental oxygen via high-flow nasal cannula or noninvasive ventilation
•Tier 4: Critical illness – Requirement for supplemental oxygen via mechanical ventilation or extracorporeal membrane oxygenation
OUTPATIENT MANAGEMENT —
Outpatient management of children with SARS-CoV-2 infection is focused on provision of symptomatic and supportive care, prompt provision of outpatient therapy for select patients at high risk of progression to severe disease, monitoring for clinical deterioration, and prevention of transmission to others (isolation) [16].
Symptomatic and supportive care — Symptomatic care for COVID-19 in the outpatient setting is similar to that for other upper respiratory or gastrointestinal clinical syndromes and discussed elsewhere. Either nonsteroidal anti-inflammatory drugs or acetaminophen may be used as needed for symptomatic treatment of pain or discomfort.
●Fever (see "Fever in infants and children: Pathophysiology and management", section on 'Management of fever')
●Upper respiratory tract infection (see "The common cold in children: Management and prevention")
●Pharyngitis (see "Acute pharyngitis in children and adolescents: Symptomatic treatment", section on 'Symptomatic treatment')
●Acute gastroenteritis (see "Acute viral gastroenteritis in children in resource-abundant countries: Management and prevention", section on 'Management')
Decision to start antivirals — We suggest outpatient antiviral therapy for children with mild-to-moderate COVID-19 disease who are at high risk for progression to severe disease (algorithm 1). Robust evidence associating specific underlying conditions with progression to severe illness in children is limited [17,18]. Nevertheless, we include presence of the underlying conditions that appear in the Pediatric Infectious Diseases Society Pediatric COVID-19 Therapies Taskforce guidelines in our decision (table 3) [16,19,20]. (See 'Risk stratification' above.)
Available pharmacologic outpatient therapies for children and adolescents with SARS-CoV-2 infection must be initiated within five to seven days of symptom onset, which requires that decisions about treatment be made as soon as possible after a positive test.
Choice of antivirals — When outpatient antiviral therapy is warranted for children with COVID-19, we suggest nirmatrelvir-ritonavir or intravenous (IV) remdesivir (depending on age, weight, and other factors) (algorithm 1 and table 3). We prefer nirmatrelvir-ritonavir for children who meet age and weight criteria, can swallow pills, and are not on medications with a potential drug-drug interaction. Although there is limited information about the effectiveness of these interventions in children and adolescents, in randomized trials in nonhospitalized adults, they substantially reduced the risk of hospitalization. (See "COVID-19: Evaluation and management of adults with acute infection in the outpatient setting", section on 'Treatment with COVID-19-specific therapies'.)
Molnupiravir, used off-label, is an alternative for patients ≥18 years of age if nirmatrelvir-ritonavir and remdesivir are unavailable or clinically inappropriate, but it should not be used in children <18 years of age. Not all experts agree with its use in adults to treat COVID-19. (See "COVID-19: Evaluation and management of adults with acute infection in the outpatient setting", section on 'Therapies with limited role or uncertain benefit'.)
We choose among the suggested therapies (summarized in the table) (table 3) on a case-by-case basis, considering the following [21]:
●Duration of symptoms – All of the available outpatient therapies should be initiated as soon as possible after a positive SARS-CoV-2 test. These medications should not be used when the child's symptom onset is beyond the following:
•Five days for nirmatrelvir-ritonavir
•Seven days for remdesivir
●Feasibility of administering parenteral medications (eg, remdesivir).
●Feasibility of administering oral medications (eg, nirmatrelvir-ritonavir tablets cannot be chewed, broken, or crushed).
●Child's age and weight – The therapies are approved or authorized for particular age groups:
•No minimum age, weight ≥1.5 kg – Remdesivir (US Food and Drug Administration [FDA] approved)
•Age ≥12 years and weight ≥40 kg – Nirmatrelvir-ritonavir (emergency use authorization [EUA])
•Age ≥18 years – Molnupiravir (off-label)
●Comorbidities and potential for drug-drug interactions (particularly with nirmatrelvir-ritonavir). (See 'Nirmatrelvir-ritonavir' below.)
Patients should not receive more than one antiviral therapy.
Nirmatrelvir-ritonavir — Nirmatrelvir-ritonavir is an oral protease inhibitor that prevents viral replication. It is expected to retain activity against current and future Omicron subvariants, but data are limited [22].
The FDA issued an EUA for nirmatrelvir-ritonavir for the treatment of mild-to-moderate COVID-19 disease in adults and children who are ≥12 years of age and weigh ≥40 kg who are at high risk for progression to severe disease (table 3) [23]. In randomized trials in adult outpatients, nirmatrelvir-ritonavir reduced the risk of hospitalization or death [24-27]. Data in children are limited [28]. (See "COVID-19: Evaluation and management of adults with acute infection in the outpatient setting", section on 'Nirmatrelvir-ritonavir as preferred therapy'.)
●Timing and dose – Nirmatrelvir-ritonavir should be initiated as soon as possible following COVID-19 diagnosis and within five days of symptom onset. The dose varies according to estimated glomerular filtration rate (eGFR) [23]:
•eGFR ≥60 mL/min (normal kidney function) – Nirmatrelvir 300 mg (two 150 mg tablets) and ritonavir 100 mg taken together orally twice daily for five days
•eGFR 30 to 59 mL/min (moderately reduced kidney function) – Nirmatrelvir 150 mg and ritonavir 100 mg taken together orally twice daily for five days
•eGFR <30 mL/min (severely reduced kidney function) – Nirmatrelvir 300 mg (two 150 mg tablets) and ritonavir 100 mg taken together orally once (day 1) and nirmatrelvir 150 mg and ritonavir 100 mg taken together orally once daily (days 2 to 5)
When prescribing nirmatrelvir-ritonavir, specify the dose for each active ingredient to avoid dosing errors and facilitate the provision of the correct packaging configuration [29].
●Contraindications and precautions
•Organ dysfunction – Nirmatrelvir-ritonavir is not recommended for patients with eGFR <30 mL/min or for patients with severe hepatic impairment (Child-Pugh class C) (table 4).
•Drug interactions – Nirmatrelvir-ritonavir is a CYP3A inhibitor, and coadministration is contraindicated with drugs that are highly dependent upon CYP3A for clearance and in which an elevated level may be dangerous [23]. Coadministration is also contraindicated with potent CYP3A inducers, which may reduce levels of nirmatrelvir and/or ritonavir and result in loss of efficacy or resistance.
Specific interactions of nirmatrelvir-ritonavir with other medications may be determined using the drug interactions program included in UpToDate. The FDA provides a patient eligibility screening checklist and guidance for managing drug interactions with nirmatrelvir-ritonavir [30,31]; the Infectious Diseases Society of America also provides guidance for the management of drug interactions with nirmatrelvir-ritonavir [32].
•Human immunodeficiency virus (HIV) – The decision to use nirmatrelvir-ritonavir in patients with uncontrolled/untreated HIV should factor in the potential risk of causing HIV protease inhibitor resistance [23].
●Rebound – There have been reports of recurrent symptoms and/or a positive SARS-CoV-2 test ("rebound" COVID-19) two to eight days after completion of treatment with nirmatrelvir-ritonavir [33]. In such cases, the Centers for Disease Control and Prevention recommend that the isolation period be restarted. Limited evidence suggests that recurrent disease is mild, and evidence that another course of antiviral therapy is beneficial is lacking. In addition, recurrent symptoms also occur in patients who are not treated with nirmatrelvir-ritonavir or other medications [34-36]. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Isolation at home' and "COVID-19: Evaluation and management of adults with acute infection in the outpatient setting", section on '"Rebound" COVID-19 after treatment'.)
Remdesivir — Remdesivir is a prodrug of a nucleotide analog that inhibits ribonucleic acid (RNA)-dependent RNA polymerase and has activity against coronaviruses [37-41]. In the United States, remdesivir has been approved by the FDA for the treatment of COVID-19 in both hospitalized and nonhospitalized adults and children who weigh ≥1.5 kg [42-44].
IV remdesivir is commercially available and another option for nonhospitalized children with a positive test for SARS-CoV-2, who have symptomatic mild-to-moderate COVID-19 and are at risk for progression to severe disease [45]. In a randomized trial in nonhospitalized adults with at least one risk factor for disease progression, remdesivir reduced the risk of hospitalization [46]. Data in children are limited [28].
●Timing and dose – Remdesivir should be initiated as soon as possible and within seven days of symptom onset. It is dosed according to weight as follows [43]:
•≥1.5 kg to <3 kg – 2.5 mg/kg IV on day 1, followed by 1.25 mg/kg IV on days 2 and 3
•>3 kg to <40 kg – 5 mg/kg IV on day 1, followed by 2.5 mg/kg IV on days 2 and 3
•≥40 kg – 200 mg IV on day 1, followed by 100 mg IV on days 2 and 3
The usual duration of therapy is three days.
Given the three-day IV regimen, remdesivir may be most feasible for children and adolescents residing in skilled nursing facilities.
●Adverse effects – Reported adverse effects of remdesivir include nausea, vomiting, and transaminase elevations. In a review of compassionate use of remdesivir in 77 children hospitalized with severe SARS-CoV-2 infection, 33 percent had adverse events and 16 percent had serious adverse events, most of which were related to COVID-19 or underlying conditions (eg, hypoxia, acute respiratory failure, recurrence of acute lymphocytic leukemia) [47]. The only adverse events to occur in more than one patient were elevation of serum aminotransferases (in nine) and anemia (in two). Cases of bradycardia attributable to remdesivir have also been reported [48-51].
Monitoring for deterioration — Caregivers of children who are managed at home should be counseled about symptoms of clinical deterioration, which may occur suddenly after approximately one week of symptoms and should prompt urgent re-evaluation, ideally at a medical center with expertise in caring for children with COVID-19 [52].
Manifestations of clinical deterioration include [53-56]:
●Severe respiratory distress, difficulty breathing (for infants: grunting, central cyanosis, inability to breastfeed)
●Chest pain or pressure
●Blue lips or face
●Findings associated with shock (eg, cold, clammy, mottled skin; new confusion; difficulty arousing; substantially reduced urine output)
●Inability to drink or keep down any liquids
Isolation at home — Isolation at home is discussed in detail separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the home setting' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Duration and subsequent precautions'.)
INPATIENT MANAGEMENT
Supportive care for all patients — We provide supportive care for all pediatric patients with COVID-19 as recommended by various national committees [16,18,21]. Supportive care is the mainstay of therapy for patients with severe or critical COVID-19 [57]. Most children with COVID-19 improve with supportive care, even those with severe disease [18]. (See "COVID-19: Clinical manifestations and diagnosis in children", section on 'Society guideline links'.)
Supportive care measures include respiratory support, fluid and electrolyte support, and empiric antibiotics as indicated for community-acquired or health care-associated pneumonia.
Thromboprophylaxis — Interventions to reduce the risk of venous thromboembolism (VTE) may be warranted for children hospitalized with COVID-19 [58,59].
We suggest using nonpharmacologic strategies for VTE prophylaxis (eg, intermittent pneumatic compression devices [size permitting] and early mobilization) and adding pharmacologic management when necessary.
For hospitalized children without multisystem inflammatory syndrome in children (MIS-C), we make decisions about pharmacologic VTE prophylaxis on a case-by-case basis, considering other VTE risk factors (table 5) and the child's risk of bleeding. The pharmacologic approach to VTE prophylaxis in hospitalized children is discussed separately. (See "Venous thrombosis and thromboembolism (VTE) in children: Treatment, prevention, and outcome", section on 'Approach to VTE prophylaxis'.)
The risk of thrombotic complications in children with COVID-19 has not been well defined. In two multicenter cohort studies (one from the United States, the other from Spain, each including >400 patients), between 1 and 2 percent of children hospitalized with SARS-CoV-2 (excluding children with MIS-C) had thrombotic complications (eg, deep vein thrombosis of the upper or lower extremity, pulmonary embolism, intracardiac thrombosis, cerebral sinovenous thrombosis) [60,61]. Most of the patients with thrombotic complications were ≥12 years of age; many had risk factors for thrombosis, and some received thromboprophylaxis before developing thrombosis. Underlying risk factors for thrombosis included cancer, obesity, critical illness, and central venous catheter. The usefulness of D-dimer >5 times the upper limit of normal as a predictor of thrombosis was inconsistent.
The risk of VTE in children with MIS-C and VTE prophylaxis for children with MIS-C are discussed separately. (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management and outcome", section on 'Antithrombotic therapy'.)
Monitoring for cytokine release syndrome — We monitor patients with severe disease for cytokine release syndrome by monitoring blood pressure for hypotension, oxygen saturation for worsening hypoxemia, and biomarkers. (See "Cytokine release syndrome (CRS)".)
●We obtain baseline C-reactive protein (CRP), D-dimer, ferritin, lactate dehydrogenase (LDH), and interleukin-6 (IL-6).
●We monitor CRP, D-dimer, ferritin, and LDH two or three times per week or if there is concern for worsening disease.
Decision to start pharmacotherapy — We suggest antiviral therapy for children hospitalized with documented COVID-19 and a new or increased supplemental oxygen requirement (algorithm 1 and table 2).
Decisions to use antiviral and other pharmacotherapies to treat patients hospitalized with COVID-19 should be individualized according to the extent of supplemental oxygen support required:
●New or increased requirement for supplemental oxygen via nasal cannula (see 'New or increased requirement for supplemental oxygen via nasal cannula' below)
●New or increased requirement for supplemental oxygen via high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) (see 'New or increased requirement for supplemental oxygen via HFNC or NIV' below)
●Requirement for supplemental oxygen via mechanical ventilation or extracorporeal membrane oxygenation (ECMO) (see 'Requirement for supplemental oxygen via mechanical ventilation or ECMO' below)
If the patient is hospitalized for a different indication and also has COVID-19, refer to outpatient management guidelines. (See 'Decision to start antivirals' above and 'Choice of antivirals' above.)
Studies of the effectiveness and safety of antiviral therapy have predominantly been performed in adults with severe lower respiratory tract disease and are discussed in detail separately. (See "COVID-19: Management in hospitalized adults", section on 'Specific treatments'.)
Given the lack of data from controlled trials supporting the efficacy of antiviral agents for the treatment of COVID-19 in children [62], we agree with the Pediatric Infectious Diseases Society (PIDS) Pediatric COVID-19 Therapies Taskforce and other experts that antiviral therapy should be considered on a case-by-case basis [16].
Choice of pharmacotherapies — Choice of pharmacotherapeutic agent(s) is based on the extent of supplemental oxygen support required (algorithm 1).
New or increased requirement for supplemental oxygen via nasal cannula — We treat patients hospitalized with COVID-19 that have a new or increased requirement for supplemental oxygen with remdesivir, in agreement with the PIDS pediatric COVID-19 guidelines [16]. The optimal role of remdesivir in patients with COVID-19 remains uncertain, and some experts suggest not using it in hospitalized patients [63,64].
Although data regarding the benefits of remdesivir for children with COVID-19 are limited, it is preferred to supportive care only because data from randomized and observational studies in adult patients suggest that it may reduce time to recovery (particularly in patients who are not critically ill); it appears to be well tolerated [18,65-74]. Studies of remdesivir in adult patients with COVID-19 are discussed separately. (See "COVID-19: Management in hospitalized adults", section on 'Remdesivir'.)
We provide remdesivir for five days or until hospital discharge, whichever comes first. The dose is based on weight:
●≥1.5 kg to <3 kg – 2.5 mg/kg IV on day 1, followed by 1.25 mg/kg IV for remainder of course
●≥3 to <40 kg – 5 mg/kg intravenously (IV) on day 1, followed by 2.5 mg/kg IV for remainder of course
●≥40 kg – 200 mg IV on day 1, followed by 100 mg IV for remainder of course
In the United States, remdesivir was approved by the US Food and Drug Administration for the treatment of COVID-19 in adults and children who weigh ≥1.5 kg [42-44]. Licensure for use in hospitalized children <12 years of age was supported by trials in adult patients and a single-arm, open-label study in 53 unvaccinated children ≥28 days with confirmed mild, moderate, or severe SARS-CoV-2 infection (41 were <12 years of age), in which remdesivir was associated with improvement in clinical status [42,43,75,76].
When the supply of remdesivir is limited, it should be prioritized for patients who do not require ventilation (invasive or noninvasive); the benefits for those who require ventilation are uncertain [77].
New or increased requirement for supplemental oxygen via HFNC or NIV — We treat patients hospitalized with COVID-19 who have a new or increased requirement for oxygen via HFNC or NIV with a combination of remdesivir and dexamethasone [78]. If the patient has already received an antiviral agent or is outside of the requisite timeframe for an antiviral agent, we treat with dexamethasone alone.
Dexamethasone dosing [79]:
●Dexamethasone 0.15 mg/kg orally, IV, or nasogastrically (NG; maximum dose 6 mg) every 24 hours
Alternative glucocorticoid dosing:
●Prednisolone 1 mg/kg orally or NG once daily (maximum dose 40 mg)
●Methylprednisolone 0.8 mg/kg IV once daily (maximum dose 32 mg)
•For neonates (<1 month of age) – 0.5 mg/kg IV every 12 hours for seven days followed by 0.5 mg/kg IV once daily for three days
•For children ≥1 month of age – 1.3 mg/kg IV every 8 hours (maximum dose 50 mg; maximum total daily dose 150 mg)
If the patient is already receiving a different glucocorticoid (eg, methylprednisolone) for another medical condition, it does not need to be replaced with dexamethasone, provided that the dose equivalent is at or above the 6 mg dexamethasone dose.
The duration of glucocorticoid therapy is up to 10 days or until discharge, whichever is shorter. In an observational study in adults, extending glucocorticoid therapy beyond discharge was not associated with decreased rates of readmission or death [80].
The use of glucocorticoids is supported by trials comparing glucocorticoids with placebo or usual care, predominantly in adult patients with severe or critical COVID-19. In these trials, glucocorticoids were associated with decreased mortality in adult patients [81-83]; however, trials in children are ongoing and the benefits and risks are uncertain. (See "COVID-19: Management in hospitalized adults", section on 'Dexamethasone and other glucocorticoids'.)
The World Health Organization also strongly recommends systemic glucocorticoids for patients with severe or critical COVID-19 but acknowledges that the applicability of the recommendation for children is uncertain given their underrepresentation in the trials supporting benefit [84]. (See 'Society guideline links' below.)
Requirement for supplemental oxygen via mechanical ventilation or ECMO — We consider treating patients requiring mechanical ventilation or ECMO with tocilizumab plus a glucocorticoid.
Tocilizumab is a monoclonal antibody that reduces inflammation by blocking the IL-6 receptor. It is used in the management of several rheumatologic conditions in children and adults (eg, polyarticular juvenile idiopathic arthritis, systemic juvenile idiopathic arthritis, chimeric antigen receptor T cell-induced severe or life-threatening cytokine release syndrome).
Tocilizumab is dosed according to patient weight [85]:
●<30 kg – 12 mg/kg IV in a single 60-minute infusion
●≥30 kg – 8 mg/kg IV in a single 60-minute infusion (maximum 800 mg per infusion)
Tocilizumab may be repeated once ≥8 hours after the initial infusion if clinical signs or symptoms worsen or do not improve after the first dose.
Tocilizumab is approved for the treatment of COVID-19 in hospitalized adult patients who are receiving systemic glucocorticoids and require supplemental oxygenation, mechanical ventilation (noninvasive or invasive), or ECMO [86]. It has emergency use authorization for treatment of such hospitalized children ≥2 years of age [85]. However, there is limited information about the benefits and risks of tocilizumab in children with COVID-19 [16,45,87].
Tocilizumab may reduce duration of hospitalization and mortality in adults with COVID-19, but the findings are inconsistent [88,89]. Studies describing the use of tocilizumab in adult patients with COVID-19 are discussed separately. (See "COVID-19: Management in hospitalized adults", section on 'IL-6 pathway inhibitors (eg, tocilizumab)'.)
Tocilizumab should be avoided in individuals with hypersensitivity to tocilizumab, uncontrolled serious infections other than COVID-19, absolute neutrophil count <1000 cells/microL, platelet counts <50,000/microL, alanine aminotransferase >5 times the upper limit of normal, or elevated risk for gastrointestinal perforation [85]. Tocilizumab should be used with caution in immunocompromised individuals because very few were included in randomized trials.
Administration of live vaccines (eg, measles, mumps, rubella, varicella) should be deferred for at least two weeks after the final infusion of tocilizumab [90]; some experts would wait at least four weeks before administration of live vaccines.
Serious adverse events in adults include tuberculosis, bacterial, and fungal infections and bowel perforation [91]. There are no data on adverse events in children.
FOLLOW-UP —
The type (eg, telehealth versus in-person visit with primary care provider or specialist), timing, and content of follow-up for children and adolescents recovering from acute SARS-CoV-2 infection is individualized according to underlying comorbidities, severity of illness, persistence of symptoms, and complications. Follow-up of children with multisystem inflammatory syndrome in children (MIS-C) is discussed separately (see "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) management and outcome"). For all other children, we follow the guidance provided by the American Academy of Pediatrics [92].
The follow-up visit should address [92]:
●Ongoing and newly developed symptoms, including cardiorespiratory symptoms, loss of smell or taste (may manifest in feeding changes in young children), neurodevelopmental symptoms (eg, motor, cognitive, language impairment; inattention; memory problems), fatigue, headache, and mental health sequelae [92]. In addition, children with a history of SARS-CoV-2 infection should be screened for diabetes symptoms (eg, increased thirst, increased hunger, frequent urination, weight loss, fatigue, abdominal pain, nausea, vomiting); SARS-CoV-2 infection has been associated with increased incidence of diabetes mellitus in some, but not all, studies [93-101].
Children with ongoing symptoms and worrisome signs should be evaluated as clinically indicated (eg, for myocarditis or MIS-C, intracranial pathology in children with headache and worrisome features).
Additional testing or referral to a multidisciplinary post-COVID-19 clinic may be warranted for children whose symptoms persist for >12 weeks [92]. (See "COVID-19: Clinical manifestations and diagnosis in children", section on 'Post-COVID-19 condition ("long COVID")'.)
●COVID-19 immunization (if eligible) and catch-up of routine immunizations (if necessary). (See "COVID-19: Vaccines" and "Standard immunizations for children and adolescents: Overview", section on 'Catch-up schedule'.)
●Reinforcement of strategies to prevent infection. (See 'Use of masks to prevent transmission' below.)
●Education about symptoms that should prompt re-evaluation. (See 'Symptomatic and supportive care' above.)
Testing for SARS-CoV-2 after recovery is not recommended unless the child or adolescent is newly symptomatic or has been exposed to someone recently diagnosed with SARS-CoV-2 infection. A negative SARS-CoV-2 test is not necessary to discontinue isolation but may be used to determine when masking can be discontinued [102]. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Isolation at home' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Duration and subsequent precautions'.)
USE OF MASKS TO PREVENT TRANSMISSION —
The Centers for Disease Control and Prevention (CDC) recommends that individuals ≥2 years of age wear a high-quality, well-fitting, comfortable face mask if they have symptoms, have tested positive for SARS-CoV-2, or have been exposed to someone with COVID-19 [103-105]. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Wearing masks in the community'.)
In addition, although local regulations should be followed, the CDC recommends that individuals ≥2 years of age wear a high-quality, well-fitting, comfortable face mask when they are in indoor public settings in areas where the COVID-19 community level is high [103,106,107]. Masks that are most protective, fit well, and will be worn consistently are preferred; the preferred mask type may vary from person to person [108]. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Viral evolution and variants of concern'.)
When the COVID-19 community level is medium or low and local regulations do not require masks in indoor public settings, the CDC and American Academy of Pediatrics (AAP) suggest that decisions about wearing masks in indoor settings should be individualized according to the child and family's circumstances (eg, whether household and other contacts are vaccinated, immunocompromised, at high risk of severe disease) [105,107].
The AAP provides additional information about face masks for children, including tips for increasing proper mask wearing and use and guidance for indoor and outdoor mask use in unvaccinated children. Recommendations from the CDC and AAP regarding face masks for children and adolescents in the school setting are provided below. (See 'In-person school and child care' below.)
Additional details are available in the World Health Organization's living guideline [109]. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Wearing masks in the community'.)
Additional information related to transmission from infected parent to newborn, children with documented or suspected COVID-19, and asymptomatic children with potential exposure are discussed in separate topics.
●(See "COVID-19: Epidemiology, virology, and prevention".)
●(See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)
●(See "COVID-19: Intrapartum and postpartum issues", section on 'Postpartum care of infected patients'.)
The CDC provides information for preventing transmission to children who are immunocompromised [110].
PRE- AND POSTEXPOSURE PROPHYLAXIS
Monoclonal antibodies are no longer recommended or available for postexposure prophylaxis, although they do play a limited role in preexposure prophylaxis for select patient populations. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Pre-exposure prophylaxis'.)
We avoid postexposure prophylaxis with hydroxychloroquine. In a meta-analysis of three randomized trials [111-113], rates of symptomatic infection (approximately 9 percent), hospitalization (<1 percent), and death (<1 percent) were similar in hydroxychloroquine and placebo groups [21]. We also avoid postexposure prophylaxis with ivermectin. (See "COVID-19: Epidemiology, virology, and prevention", section on 'Interventions with no preventive role'.)
IN-PERSON SCHOOL AND CHILD CARE —
A number of professional organizations provide guidance regarding in-person school and child care attendance, including:
●ABC Science Collaborative, developed by the Duke School of Medicine and the Duke Clinical Research Institute
●American Academy of Pediatrics [114], which provides specific guidance on:
•Safe transportation in motor vehicles [115]
•Child care [116]
●The Centers for Disease Control and Prevention (CDC) operational guidance for K-12 schools and early care and education programs to support safe in-person learning [117]
●The eSchool+ Initiative, a cross-disciplinary collaboration from Johns Hopkins University
●National Academies of Sciences, Engineering, and Medicine [118]
●Washington University Pediatric and Adolescent Ambulatory Research Consortium [119]
●World Health Organization (WHO) [120]
•Considerations for school-related public health measures in context of COVID-19
Key recommendations include [114,117,118,120-123]:
●Promotion of vaccination for eligible staff and students [124].
●Inclusion of multiple perspectives (eg, public health and infectious disease experts, educators, parents/caregivers, teachers, community leaders) and permit regional variation.
●Having training and safeguards in place (eg, protocols and necessary supplies and personnel for hand hygiene, face masks, cleaning, disinfection, ventilation, symptom screening, testing). Multilayered mitigation strategies are particularly important with widespread circulation of highly transmissible variants (eg, Delta [B.1.617.2], Omicron [B.1.1.529]) [125].
In the school or child care setting, the CDC recommends that masks be worn indoors by all individuals ≥2 years of age, including those who are up to date with their COVID-19 vaccinations, in areas where the COVID-19 community level is high [107].
●Establishing a protocol for monitoring and responding to changes in transmission in the school or community as well as children with COVID-19 symptoms or exposure [117,119,121].
●Providing realistic and practical mitigation strategies with flexibility to accommodate different types of students (eg, young children, those with developmental disabilities), classroom/school environments (eg, size, ventilation), and other factors.
●Consideration of the benefits and risks for all concerned parties (students, staff, parents/caregivers, community); the magnitude of benefits and risks may differ for students and teachers/staff. In addition to education, schools provide services to children with special health care needs, meals, opportunities to develop social/emotional skills, and physical activity. In a 2018 national survey, approximately 50 percent of adult teachers and adults living with school-aged children had conditions that are considered definite or possible risk factors for severe COVID-19 [126].
●Special considerations for vulnerable populations (eg, those with developmental challenges, those who are medically fragile or live in poverty) [127].
The eSchool+ Initiative provides a tracker that categorizes school reopening plans according to consideration of 12 categories (eg, core academics, SARS-CoV-2 protection, food and nutrition, caregiver choice, teacher and staff choice, children of poverty and disadvantage).
SPORTS AND EXTRACURRICULAR ACTIVITIES —
Decisions about participation in sports and extracurricular activities for children and adolescents should be made on a case-by-case basis in accordance with local regulations and guidance [121,128,129]. Factors to consider include local disease activity, COVID-19 vaccination status, and other mitigation measures (eg, mask wearing, ventilation) and whether the activities increase the risk of transmission among students or staff (eg, by resulting in or requiring deep breathing [eg, intense exercise, shouting, singing]). Observational studies suggest that the risk of transmission is lower with outdoor than indoor sports activity [130]. Although indoor sports (eg, wrestling, gymnastics, ice hockey), close contact team sports, and intense exercise have been associated with increased transmission [131-136], there are reports of successful implementation of stringent mitigation protocols [137]. Social gatherings associated with team sports also may increase the risk of transmission [129].
Return to play or strenuous activity following infection is discussed separately (algorithm 2). (See "COVID-19: Return to sport or strenuous activity following infection".)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: COVID-19 – Pediatrics".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Basics topics (see "Patient education: COVID-19 and children (The Basics)" and "Patient education: COVID-19 overview (The Basics)" and "Patient education: COVID-19 vaccines (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Assessment of severity – We use the following guidelines to categorize levels of COVID-19 illness severity (table 2):
•Tier 1: Mild illness – No new or increased supplemental oxygen requirement.
•Tier 2: Moderate illness – New or increased requirement for supplemental oxygen via nasal cannula.
•Tier 3: Severe illness – New or increased requirement for supplemental oxygen via high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV).
•Tier 4: Critical illness – Requirement for supplemental oxygen via mechanical ventilation or extracorporeal membrane oxygenation (ECMO).
●Determine management setting
•Most children with documented or suspected COVID-19 and mild symptoms (eg, fever, cough, pharyngitis, other respiratory symptoms) can be managed at home with symptomatic and supportive care.
•Indications for hospitalization of children with COVID-19 include new or increased requirement for supplemental oxygen (table 2) or fever in an infant younger than 30 days. (See 'Determine management setting' above.)
●Outpatient management
•Symptomatic and supportive care for COVID-19 in the outpatient setting is the mainstay of treatment and is similar to that for other upper respiratory or gastrointestinal clinical syndromes.
•In children with mild-to-moderate COVID-19 illness who are at high risk for progression to severe illness (table 1), we suggest nirmatrelvir-ritonavir rather than remdesivir or no antiviral therapy (Grade 2C). This applies to children who meet criteria for nirmatrelvir-ritonavir use, can swallow pills, and are not on medications with potential drug-drug interactions that cannot be mitigated (ie, medication cannot be discontinued) (table 3). Remdesivir is a reasonable alternative if the child is unable to be treated with nirmatrelvir-ritonavir. (See 'Choice of antivirals' above.)
•Additional management is focused on monitoring for clinical deterioration (eg, difficulty breathing, cyanosis, symptoms of shock) and prevention of transmission to others (ie, isolation). (See 'Monitoring for deterioration' above and 'Isolation at home' above and 'Use of masks to prevent transmission' above.)
●Inpatient management
•Supportive care – Supportive care (eg, respiratory support, fluid and electrolyte support, monitoring for cytokine release syndrome) is an important aspect of therapy for children with moderate, severe, or critical COVID-19 illness. (See 'Supportive care for all patients' above.)
•Pharmacotherapy – Pharmacotherapy is reserved for patients with a new or increased requirement for oxygen supplementation as follows (see 'Choice of pharmacotherapies' above):
-New or increased requirement for supplemental oxygen via nasal cannula – In children with a new or increased requirement for supplemental oxygen via nasal cannula, we suggest treatment with remdesivir rather than other agents or supportive care alone (Grade 2C). (See 'New or increased requirement for supplemental oxygen via nasal cannula' above.)
-New or increased requirement for supplemental oxygen via HFNC or NIV – In children with a new or increased requirement for supplemental oxygen via HFNC or NIV, we suggest combination therapy with remdesivir and dexamethasone rather than either agent alone (Grade 2C). If the child is not eligible for antiviral therapy, dexamethasone can be administered as monotherapy. (See 'New or increased requirement for supplemental oxygen via HFNC or NIV' above.)
-Requirement for supplemental oxygen via mechanical ventilation or ECMO – In children that require mechanical ventilation or ECMO, we suggest treatment with a glucocorticoid plus tocilizumab rather than no additional pharmacotherapy (Grade 2C). (See 'Requirement for supplemental oxygen via mechanical ventilation or ECMO' above.)
●Follow-up – The follow-up visit should address ongoing and newly developed symptoms, COVID-19 immunization, reinforcement of strategies to prevent infection, and education about symptoms that should prompt re-evaluation. (See 'Follow-up' above.)
