Information For Pediatric Healthcare Providers

Who this is for: Pediatric Healthcare Providers

What that is for: To inform pediatric healthcare suppliers of knowledge available on children with COVID-19.

How to use: Refer to this info when managing pediatric patients with confirmed or suspected COVID-19. For healthcare suppliers caring for neonates (≤28 days old), please refer to CDC guidance for evaluating and managing neonates in danger for COVID-19.

Maintaining Childhood Immunizations and Well-Child Care During COVID-19 Pandemic

Stay-at-residence and shelter-in-place orders have resulted in declines in outpatient pediatric visits andfewer vaccine doses being administered, leaving children in danger for vaccine-preventable illnesses. As states develop plans for reopening, healthcare suppliers are encouraged to work with households to maintain or bring youngsters up to date with their vaccinations. Primary care practices in communities affected by COVID-19 should proceed to usestrategies to separate properly visits from sick visitsexternal icon. Examples may embody:

* Scheduling sick visits and properly-child visits during completely different occasions of the day
* Reducing crowding in waiting rooms, by asking sufferers to remain outdoors (e.g., keep of their automobiles, if relevant) till they’re known as into the ability for his or her appointment, or establishing triage booths to screen sufferers safely
* Collaborating with healthcare suppliers in the neighborhood to determine separate locations for providing nicely visits for children

Healthcare providers should establish youngsters who have missed nicely-child visits and/or beneficial vaccinations and contact them to schedule in individual appointments, starting with newborns, infants as much as 24 months, younger youngsters and increasing by way of adolescence. State-based immunization data systems and digital well being information may be able to support this work.

All newborns ought to be seen by a pediatric healthcare provider shortly after hospital discharge (three to 5 days of age). Ideally, newborn visits must be accomplished in individual during the COVID-19 pandemic in order to evaluate for dehydration and jaundice, ensure all components of new child screening had been accomplished and applicable confirmatory testing and observe-up is organized, and evaluate moms for postpartum melancholy. Developmental surveillance and early childhood screenings, together with developmental and autism screening, ought to continue along with referrals for early intervention services and further analysis if considerations are recognized.

Burden of COVID-19 Among Children
Pediatric circumstances of coronavirus disease 2019 (COVID-19), attributable to extreme acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have been reported. However, there are comparatively fewer instances of COVID-19 amongst children compared to cases among grownup patients.1-5

* In the United States, 2% of confirmed circumstances of COVID-19 had been amongst individuals aged four
* In China, 2.2% of confirmed cases of COVID-19 were amongst persons aged 1
* In Italy, 1.2% of COVID-19 circumstances had been among kids aged <18 years.2
* In Spain, 0.eight% of confirmed instances of COVID-19 have been amongst persons aged 5

Among cases in children reported from China, most had exposure to family members with confirmed COVID-19.6-10

Clinical Presentation in Children
Symptoms in Pediatric Patients
Illness among pediatric instances look like gentle, with most circumstances presenting with signs of higher respiratory an infection corresponding to:

* Fever
* Cough
* Nasal congestion
* Rhinorrhea
* Sore throat

Outcomes in Pediatric Patients
Relatively few children with COVID-19 are hospitalized, and fewer youngsters than adults experience fever, cough, or shortness of breath. Severe outcomes have been reported in children together with COVID-19 associated deaths. Hospitalization was most common among pediatric sufferers aged

Although most cases reported amongst kids to date haven’t been extreme, clinicians ought to preserve a high index of suspicion for SARS-CoV-2 infection in children and monitor for development of illness, particularly among infants and youngsters with underlying circumstances.

Incubation Period
While knowledge on the incubation interval for COVID-19 within the pediatric population are limited, it’s thought to extend to 14 days, just like grownup patients with COVID-19.eleven In studies from China, the reported incubation interval among pediatric patients ranged from 2 to 10 days.7,12

Clinical Presentation
Pediatric patients with COVID-19 may experience the following indicators or symptoms over the course of the illness:3,4,6, * Fever
* Cough
* Nasal congestion or rhinorrhea
* Sore throat
* Shortness of breath
* Diarrhea
* Nausea or vomiting
* Fatigue
* Headache
* Myalgia
* Poor feeding or poor appetite

The predominant indicators and symptoms of COVID-19 reported to date among all patients are similar to different viral respiratory infections, together with fever, cough, and shortness of breath. Although these signs and signs could occur at any time through the general disease course, children with COVID-19 could not initially present with fever and cough as usually as grownup patients.four,15,sixteen In a report of 9 hospitalized infants in China with confirmed COVID-19, only half presented with fever.9 Gastrointestinal signs, including abdominal ache, diarrhea, nausea, and vomiting, had been reported in a minority of grownup patients.17 In one pediatric case of COVID-19, diarrhea was the one symptom reported.10

There have been a number of reports so far of children with asymptomatic SARS-CoV-2 an infection.three,6,14,15 In one research, up to thirteen% of pediatric circumstances with SARS-CoV-2 infection were asymptomatic.16 The prevalence of asymptomatic SARS-CoV-2 infection and length of pre-symptomatic infection in youngsters usually are not nicely understood, as asymptomatic people are not routinely examined.

Signs and symptoms of COVID-19 in children could also be much like those for widespread viral respiratory infections or other childhood illnesses. It is necessary for pediatric providers to have an appropriate suspicion of COVID-19, but additionally to proceed to contemplate and check for different diagnoses, similar to influenza (see CDC’s Flu Information for Healthcare Professionals for extra information).

Clinical Course and Complications in Children
The largest research of pediatric sufferers (>2,000) with COVID-19 from China reported that sickness severity ranged from asymptomatic to important:16

* Asymptomatic (no medical signs or symptoms with regular chest imaging): 4%
* Mild (mild symptoms, together with fever, fatigue, myalgia, cough): 51%
* Moderate (pneumonia with signs or subclinical disease with irregular chest imaging): 39%
* Severe (dyspnea, central cyanosis, hypoxia): 5%
* Critical (acute respiratory misery syndrome [ARDS], respiratory failure, shock, or multi-organ dysfunction): 0.6%

Based on these early studies, youngsters of all ages are at risk for COVID-19; however, complications of COVID-19 appear to be less widespread amongst children compared with adults based on limited reports from China16 and the united statesfour,18 In children, SARS-CoV-2 might have more affinity for the upper respiratory tract (together with nasopharyngeal carriage) than the decrease respiratory tract.sixteen

As of April 2, 2020, infants aged four However, this age group remains underrepresented among COVID-19 cases in patients of all ages (zero.three%) in comparison with their percentage in the U.S. population (1.2%). Relative to grownup patients with COVID-19, there have been fewer children with COVID-19 requiring hospitalization (6–20%) and ICU admission (zero.6–2%).four Although severe issues (e.g., acute respiratory misery syndrome, septic shock) have been reported in youngsters of all ages,four,9,12,19 they appear to be infrequent. Based on limited data on youngsters with either suspected or confirmed infection with SARS-CoV-2, infants (sixteen with hospitalization being most common among children aged 4 Other reports describe a light disease course, including in infants.7,9,16

In the United States, as of April 2, 2020, there have been three deaths among kids with laboratory-confirmed SARS-CoV-2 infection which have been reported to CDC, however the contribution of SARS-CoV-2 an infection to the cause of death in these instances is unclear.4

Multisystem Inflammatory Syndrome in Children (MIS-C)

CDC is collaborating with domestic and worldwide partners to study extra about multisystem inflammatory syndrome in youngsters (MIS-C) associated with COVID-19.

Patients with MIS-C have introduced with a persistent fever and a wide range of indicators and symptoms including multiorgan (e.g., cardiac, gastrointestinal, renal, hematologic, dermatologic, neurologic) involvement, and elevated inflammatory markers.

Healthcare providers who have cared or are caring for sufferers younger than 21 years of age meeting MIS-C criteria ought to report suspected instances to their native, state, or territorial well being department. For extra info together with a full case definition, please visit MIS-C Information for Healthcare Providers.

Testing, Laboratory Findings, and Radiographic Findings
Diagnosis of COVID-19 requires detection of SARS-CoV-2 RNA by reverse transcription polymerase chain response (RT-PCR) testing. Testing methods, including medical standards for considering testing and really helpful specimen sort, are the same for kids and adults. CDC’s steering for evaluation and administration of neonates in danger for COVID-19 details particular testing considerations for newborns. For extra details about testing, visitEvaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19), Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for COVID-19, andFrequently Asked Questions on COVID-19 Testing at Laboratories.

There are limited knowledge on laboratory findings related to COVID-19 in pediatric patients. Unlike grownup patients with COVID-19,20,21there have been no constant leukocyte abnormalities reported in pediatric patients.22Additional research are required to know the laboratory findings associated with pediatric cases of COVID-19.

Chest x-rays of kids with COVID-19 have proven patchy infiltrates in keeping with viral pneumonia, and chest CT scans have proven nodular ground glass opacities;14,23,24 nevertheless, these findings aren’t particular to COVID-19, could overlap with other diagnoses, and some children may haven’t any radiographic abnormalities. Chest radiograph or CT alone isn’t recommended for the analysis of COVID-19. The American College of Radiology additionally doesn’t suggest CT for screening or as a first-line test for prognosis of COVID-19. (SeeAmerican College of Radiology Recommendationsexternal icon)

Treatment and Prevention
Currently, there are no specific drugs permitted by the U.S. Food and Drug Administration (FDA) for therapy or prevention of COVID-19. Treatment remains largely supportive and contains prevention and management of problems. Healthcare services, including pediatric healthcare facilities, ought to guarantee thatinfection prevention and control policies, together with common supply management, are in place to reduce likelihood of exposure to SARS-CoV-2 among providers, sufferers, and households. CDC has revealed particular steering, together with an infection prevention and management concerns, for inpatient obstetric healthcare settings and the evaluation and administration of neonates in danger for COVID-19.

The choice to manage a pediatric affected person with mild to moderate COVID-19 within the outpatient or inpatient setting should be decided on a case-by-case foundation. Pediatric healthcare providers ought to think about the affected person’s clinical presentation, requirement for supportive care, underlying conditions, and the ability for parents or guardians to take care of the kid at residence. For more data on home care of patients not requiring hospitalization visit: Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19).

There is proscribed evidence presently about which underlying medical conditions in kids would possibly increase the risk of severe sickness from COVID-19. Current evidence suggests that kids who are medically advanced, who’ve severe genetic, neurologic, metabolic disorders, and with congenital heart disease could be at increased danger for extreme illness from COVID-19. Similar to adults, youngsters with obesity, diabetes, asthma and continual lung disease, or immunosuppression may additionally be at increased risk for severe sickness from COVID-19.

Severe complications related to COVID-19 in pediatric sufferers have not been properly-described. One newly described severe complication, multisystem inflammatory syndrome (MIS-C), is being investigated by CDC and companions. The treatment of extreme and important circumstances of pediatric patients with COVID-19 in the hospital could include administration of pneumonia, respiratory failure, exacerbation of underlying conditions, sepsis or septic shock, or secondary bacterial an infection. Situations in which a affected person requires prolonged hospitalization may result in secondary nosocomial infections.

Several organizations have published guidelines associated to the treatment and administration of COVID-19 sufferers, including pediatric sufferers:

For information regarding discontinuing transmission-based precautions and disposition of sufferers with COVID-19 in healthcare settings, please see:Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance).

Additional Information
1. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of Cases From the Chinese Center for Disease Control and Prevention. JAMA
2. Livingston E, Bucher K. Coronavirus Disease 2019 (COVID-19) in Italy. JAMA
three. Su L, Ma X, Yu H, et al. The different scientific characteristics of corona virus illness circumstances between kids and their families in China – the character of kids with COVID-19. Emerging Microbes and Infection 2020; 9(1): .
4. CDC COVID-19 Response Team. Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. MMWR Morbidity and Mortality Weekly Report. ePub: 6 April 2020. DOI: /10.15585/mmwr.mm6914e4external icon.
5. Tagarro A, Epalza C, Santos M, et al. Screening and Severity of Coronavirus Disease 2019 (COVID-19) in Children in Madrid, Spain. JAMA Pediatr
6. Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and epidemiological options of 36 kids with coronavirus illness 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Lancet Infect Dis
7. Cai J, Xu J, Lin D, et al. A Case Series of kids with 2019 novel coronavirus infection: scientific and epidemiological options. Clin Infect Dis
8. Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia related to the 2019 novel coronavirus indicating individual-to-particular person transmission: a research of a family cluster. Lancet 2020; 395(10223): .
9. Wei M, Yuan J, Liu Y, Fu T, Yu X, Zhang ZJ. Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China. JAMA
10. Ji LN, Chao S, Wang YJ, et al. Clinical options of pediatric patients with COVID-19: a report of two family cluster instances. World journal of pediatrics : WJP
eleven. Lauer SA, Grantz KH, Bi Q, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med
12. Sun D, Li H, Lu XX, et al. Clinical features of extreme pediatric sufferers with coronavirus disease 2019 in Wuhan: a single middle’s observational study. World journal of pediatrics : WJP
thirteen. Zheng F, Liao C, Fan QH, et al. Clinical Characteristics of Children with Coronavirus Disease 2019 in Hubei, China. Curr Med Sci
14. Xu Y, Li, Xufang, et al. Characteristics of pediatric SARS-CoV-2 infection and potential proof for persistent fecal viral shedding. Nature Medicine
15. Lu X, Zhang L, Du H, et al. SARS-CoV-2 Infection in Children. New England Journal of Medicine
sixteen. Dong Y, Mo X, Hu Y, et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics
17. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA
18. Team CC-R. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) – United States, February 12-March 16, 2020. MMWR Morb Mortal Wkly Rep 2020; 69(12): 343-6.
19. Kamali Aghdam M, Jafari N, Eftekhari K. Novel coronavirus in a 15-day-old neonate with scientific signs of sepsis, a case report. Infect Dis (Lond) 2020: 1-3.
20. Guan WJ, Ni ZY, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med
21. Huang C, Wang Y, Li X, et al. Clinical features of sufferers contaminated with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395(10223): .
22. Henry BM, Lippi G, Plebani M. Laboratory abnormalities in children with novel coronavirus illness 2019. Clin Chem Lab Med
23. Chen F, Liu ZS, Zhang FR, et al. [First case of extreme childhood novel coronavirus pneumonia in China]. Zhonghua er ke za zhi = Chinese journal of pediatrics 2020; 58(3): .
24. Feng K, Yun YX, Wang XF, et al. [Analysis of CT options of 15 Children with 2019 novel coronavirus an infection]. Zhonghua er ke za zhi = Chinese journal of pediatrics 2020; 58(0): E007.