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India’s guidelines on Covid-19 in children: rational use of CT scan, no Remdesivir

The government has come out with comprehensive guidelines for the management of COVID-19 among children in which Remdesivir has not been recommended and rational use of HRCT imaging has been suggested.

The guidelines issued by the Directorate General of Health Services (DGHS) under the health ministry also said that steroids are harmful in asymptomatic and mild cases of infection.

The DGHS recommended steroids only in hospitalised moderately severe and critically ill COVID-19 cases under strict supervision.

“Steroids should be used at the right time, in the right dose and for the right duration. Self-medication of steroids must be avoided,” it said.

The guidelines also said Remdesivir (an emergency use authorization drug) is not recommended in children.

“There is lack of sufficient safety and efficacy data with respect to Remdesivir in children below 18 years of age,” the guidelines said.

The guidelines suggested rational use of High-resolution CT (HRCT) for seeing the extent and nature of lung involvement in patients with COVID-19.

“However, any additional information gained from HRCT scan of the chest often has little impact on treatment decisions, which are based almost entirely on clinical severity and physiological impairment.

“Therefore, treating physicians should be highly selective in ordering HRCT imaging of the chest in COVID-19 patients,” the guidelines said.

They said COVID-19 is a viral infection, and antimicrobials have no role in the prevention or treatment of uncomplicated COVID-19 infection

For asymptomatic and mild cases, the guidelines said antimicrobials are not recommended for therapy or prophylaxis while for moderate and severe cases antimicrobials should not be prescribed unless there is clinical suspicion of a superadded infection.

Hospital admission increases the risk of healthcare-associated infections with multidrug-resistant organisms.

For asymptomatic infection among children, the guidelines recommended no specific medication and promoted COVID-appropriate behaviour (mask, strict hand hygiene, physical distancing) and suggested giving nutritious diet.

The guidelines said that for mild infection paracetamol 10-15mg/kg/dose may be given every 4-6 hours for fever and throat soothing agents and warm saline gargles in older children and adolescents have been recommended for cough.

In case of moderate infection, the guidelines suggested initiating immediate oxygen therapy.

“Corticosteroids are not required in all children with moderate illness; they may be administered in rapidly progressive disease and anticoagulants may also be indicated,” the guidelines said.

For severe COVID-19 among children, the guidelines said if Acute Respiratory Distress Syndrome (ARDS) develops, necessary management to be initiated.

“In case shock develops, necessary management should be initiated. Antimicrobials to be administered if there is evidence/strong suspicion of superadded bacterial infection. May need organ support in case of organ dysfunction, e.g. renal replacement therapy,” it said.

The guidelines also recommended a six-minute walk test for children above 12 years under the supervision of parents/guardians

“It is a simple clinical test to assess cardiopulmonary exercise tolerance and is used to unmask hypoxia. Attach a pulse oximeter to his/her finger and ask the child to walk in the confines of their room for six minutes continuously,” it said.

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