28^th August, 2021, 11am-12pm

Key points of HCFI Expert Round Table

Covid-19 in children

• The true incidence of Covid-19 in children is not known. This is due to lack of widespread testing, prioritising of tests for adults, less severe illness and fewer hospitalizations in children.
• There should be a high index of suspicion for Covid-19 in children with fever.
• In the US, children below 18 years of age constituted 12% of all cases with less than 2% requiring hospitalization. In European countries, around 9% children were affected; of which 3.5% needed intensive care.
• In Nepal, children <20 years of age accounted for nearly 9% of total cases and in Bangladesh, this figure was 10%.
• As per NCDC data, less than 12% of confirmed cases were children younger than 20 years and around 4% were children below 10 years of age.
• At CNBC, out of the total positive 9.5% cases, the positive pediatric cases were 3.9% and 0.4% required hospitalization.
• Classical Covid-19 symptoms are fever, sore throat, headache, myalgia, fatigue, coryza, poor feeding in an infant, loss of taste/smell in children older than 8 years. The atypical symptoms are diarrhea, vomiting, abdominal pain, rash, covid toes.
• Infection may be asymptomatic when the child is diagnosed when screening other family members. The infection can be mild (SpO2 >94%), moderate (SpO2 90-93%) or severe (SpO2<90%).
• Children likely have similar viral loads in the nasopharynx, similar secondary infection rates and can also spread the infection to others.
• Risk factors for severe Covid-19 include obesity, diabetes, severe malnutrition, malignancy, immunosuppression.
• Remdesivir is not recommended in children. CT chest is indicated only if there is no improvement in respiratory status. Likewise, steroids are indicated only in severe and critically ill cases.
• MISC-C is also called pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). It typically appears 4-6 weeks after the infection.
• It is important to be able to suspect and correctly diagnose MIS-C, know the list of investigations to be used judiciously, appropriate line of treatment and when to refer the child.
• Some children with MIS-C may later develop hyperinflammatory disease with manifestations similar to Kawasaki disease or toxic shock syndrome.
• Patients with Kawasaki disease diagnosed during and after Covid-19 differed from those diagnosed before, clinically and biochemically, and therefore were classified as Kawasaki-like disease. They were older, had respiratory, GI involvement including signs of cardiovascular involvement. They had leukopenia with marked lymphopenia, thrombocytopenia, increased ferritin and had markers of myocarditis. The disease was more severe.
• Several studies have characterised MIS-C in pediatric age group.
• Tier 1 tests include CBC with differential counts, CRP, ESR, RT PCR for SARS-CoV-2, dengue serology, ps for malaria, blood culture, electrolytes, LFT and KFT
• The Tier 2 tests include ferritin, LDH, PT/aPTT, fibrinogen, d-dimer, chest x-ray, echo, ECG, troponin-I, IL-6, BNP and CK.
• Tropical fevers, toxic shock syndrome and bacterial sepsis must be excluded before making a diagnosis of MIS-C.
• MIS-C treatment involves immunomodulatory treatment (IVIg, steroids, IL-6 antagonists, IL-1 antagonists and TNFa inhibitors) and supportive treatment (oxygen, IV fluids, paracetamol, anticoagulants).
• MIS-C is diagnosed only in the presence of hyperinflammatory state.
• Discharge criteria include 3-4 days of declining inflammatory markers, afebrile/without supplemental oxygen/ inotropes for 48 hours, heart failure controlled on oral medication, findings stable on echocardiography (to be repeated 7-14 days and 4-6 weeks post-discharge).
• Overall prognosis is good and most patients usually recover.
• It has been shown that children have a significant fear of Covid-19, boredom and sleep disturbances.
• Families should be helped to recognise the signs of stress such as sadness, unhealthy eating or sleeping habits, difficulty with attention and concentrations. Some children may become silent, while some may express anger and be hyperactive.
• Maintain a normal routine and keep them active, talk to and listen to children, give them accurate information and encourage them to connect to friends and family through video calls.
• Keep up with routine immunizations and routine check-ups for comorbidities.
• Nutritional care of Covid-positive children is essential; enteral feeding is preferred; if child not accepting orally, then nasogastric feeding.
• Mothers should be encouraged to breastfeed while taking all infection prevention measures.
• Maintenance fluid requirement for a 25 kg child is around 1600 ml.
• Clinically monitoring includes fever, respiratory rate, SpO2, activity level, feed intake and urine output.
• Red flag signs include child becoming lethargic, not accepting feeds and vomiting, not passing urine, high respiratory rate, chest indrawing, SpO2 <94%, cold palms and soles and bluish discoloration of body.
• Children with severe Covid-19 particularly require enhanced care and follow up for likely complications such as infections – pneumonia, mucormycosis. Home SpO2 monitoring with pulse oximeter for such children is advised.
• Family should be counseled to watch for signs of stress and anxiety and adviced about warning signs (fever, fall in SpO2, increased cough or dyspnea, headache, tooth pain, nasal blockage).
• All family members should practice infection prevention measures after discharge at home and work places.
• Masking is not recommended for children younger than 5 years.
• Schools should be reopened in a phased manner with adequate mitigating measures in place.
• Preparation for the third wave is very crucial. This includes identifying facilities for managing pediatric covid cases, strengthening of pediatric tertiary care centers and establishment of pediatric beds and ICUs.

Excerpts from presentation by Dr Mamta Jajoo, Professor Pediatrics, Chacha Nehru Bal Chikitsalaya, Delhi

Medical masks

• India needs to mask up to avoid the third wave. The pandemic is still ongoing and is not close to being over. With the emergence of newer virulent strains such as the delta variant, it is very important to protect ourselves.
• Even with full vaccination, we must continue to wear a mask. Masks are the new normal.
• Compliance to masks in India is low, despite the deadly second wave. People do not wear masks properly as also shown in a recent study, wherein 67% of citizens failed to comply with proper masking. Crowds are common and social distancing is not adhered to.
• Masks are simple and mandatory barriers, which protect from respiratory droplets.
• Masks can be said to be the PPE for the public during the ongoing pandemic.
• Universal masking is one of the most important prevention strategies recommended by the Health ministry and the CDC to slow the spread of the virus.
• Common masks filter about 10% of exhaled aerosol droplets due to problems with the fit, whereas the N95 and KN95 masks filter more than 50% of the aerosols.
• A disposable surgical mask is fluid resistant and protects against larger particles (5 microns in size) droplets and spray. The N95 mask, on the other hand, also blocks at least 95% of very small particles (0.3 microns). The size of the coronavirus is 0.3 micron.
• The RFRF (Research For Resurgence Foundation) strongly recommends use of masks of higher filtration capability for effective control of the delta plus variant.
• A fabric mask or even surgical mask is not the right mask to filter out any or all forms of virus.
• The first layer (outer; dark blue or green) of a disposable surgical mask is the fluid-repellent layer and is to be worn outwards. The third layer (inner; white) is the absorbent layer and is to be worn inside. The second layer (melt blown material infused in a non-woven fabric) is the filtering layer.
• A tight fitting N95 surgical mask achieves a close facial fit and guarantees minimal leakage from the edges of the mask on inhalation. The N95 respiratory reduces exposure to small particles and large droplets.
• NIOSH (National Institute of Occupational Safety and Health), SITRA (South India Textile and Research Association) and INMAS (Institute of Nuclear Medicine and Allied Sciences) are the three agencies have been authorised to test the efficacy of the masks and PPE kits. NIOSH/SITRA certification is mandatory for the masks.
• Factors important for optimal protection are good fit, high filtrating efficiency, high fluid resistance of the outermost layer, high thread count and good breathability. Washability without affecting the structure and efficiency are additional factors for good effectiveness.
• More than the number of layers, the filtering fabric makes the mask more efficient to prevent virus entry.
• Many masks are being sold that do not conform with the SITRA tests.
• The CDC and the Health Ministry recommend double masking to slow the spread of Covid-19. If the two masks fit well, they can produce an overall efficiency of more than 90% for particles sized 1 micron and larger.
• Coating of masks can filter virus and bacteria to nearly 100%. It also provides splash resistance to up to 140mmHg. The coating is embedded in the cotton fabric pores.
• Bio-degradable nano-silver coated masks are also available.

Excerpts from a presentation by Prof Dr Ashok Gupta, Recipient of Padma Shri, Bombay Hospital Institute of Medical Sciences, Mumbai

Participants

Dr Ashok Gupta

Dr Suneela Garg

Dr Anita Chakravarti

Dr Arun Jamkar

Dr Mamta Jajoo

Prof Bejon Misra

Dr DR Rai

Dr Jayakrishna Alapet

Dr KK Kalra

Dr Anil Kumar

Dr B Kapoor

Mrs Upasana Arora

Ms Ira Gupta

Ms Balbir Verma

Ms Priyanka Bapna

Mr Rajesh Chopra

Mr Saurabh Aggarwal

Dr S Sharma