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Table of Contents
Year : 2021  |  Volume : 18  |  Issue : 3  |  Page : 187-188

COVID-19 in children

Department of Paediatrics, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India

Date of Submission20-Jul-2021
Date of Decision22-Jul-2021
Date of Acceptance23-Jul-2021
Date of Web Publication07-Sep-2021

Correspondence Address:
Tanu Singhal
Department of Paediatrics, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_82_21

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COVID-19 disease is of mild severity in most children. The common symptoms include fever, sore throat, cough, nasal congestion, diarrhea, and vomiting. Prompt testing of suspect cases with rapid antigen test and/or reverse transcription–polymerase chain reaction in nasopharyngeal swabs is recommended. The routine use of computed tomography (CT) scan should be discouraged. For children with mild disease, only symptomatic therapy is required. Red flag signs include persistent high fever, breathlessness, drowsiness, and hypoxia. For children with moderate/severe disease, oxygen, steroids, and anticoagulation are standard of care. Vaccination of children against COVID-19 is not a priority at this time. The indirect effects of COVID-19 vastly outnumber the direct effects.

Keywords: Children, COVID-19, pneumonia

How to cite this article:
Singhal T. COVID-19 in children. Apollo Med 2021;18:187-8

How to cite this URL:
Singhal T. COVID-19 in children. Apollo Med [serial online] 2021 [cited 2021 Dec 6];18:187-8. Available from: https://www.apollomedicine.org/text.asp?2021/18/3/187/325679

  Introduction Top

Children below 18 years have contributed to around 12% of the total cases globally and in India despite constituting 25% and 40% of the population, respectively.[1] However, the latest seroprevalence survey in India has reported seroprevalence rates in children (42% aged 2–10 years and 55% aged 10–17 years) comparable to adults (63%).[2] This implies that while children are infected, they are tested less often. Furthermore, hospitalization rates in children are <5% as compared to 15%–20% in adults.[3] Finally, mortality rates in children are <0.1% as compared to 2%–3% in adults, with children contributing to only 0.3% of all COVID-19 deaths.[1] The mild affection of children is attributed to the immature angiotensin-converting enzyme 2 receptors, better innate immunity, higher circulating lymphocyte numbers, fewer comorbidities, and healthier lungs.[4] Severe disease in children is usually seen in infants and those with comorbidities.

The indirect effects of COVID-19 in children overshadow the direct effects.[1] These include loss of parents/grandparents, learning crises, mental health issues, obesity, excess screen time, poverty, child abuse, missed immunization, and inattention to other diseases.

Multisystem inflammatory syndrome in children (MIS-C) is the most dramatic manifestation of COVID-19 in children. We will not be addressing MIS-C and neonatal COVID-19 in this article.

  Clinical Features Top

Some children may be asymptomatic. The symptoms are nonspecific and mimic other viral illnesses. Common symptoms include fever, sore throat, cough, runny nose, rash, vomiting, diarrhea, and abdominal pain.[3] Headache, fatigue, loss of sense of smell, and taste are less commonly reported than adults. Most children recover in a few days.

  Classification of Disease Severity (ICMR Criteria) Top

  • Mild: Symptoms of COVID-19 with no features of lower respiratory tract involvement
  • Moderate: Fast breathing (as per age-related cutoffs) or hypoxemia (saturation 90%–93%)
  • Severe disease: Presence of retractions or saturation < 90% or severe dehydration or drowsiness/seizures
  • Critical disease: A subset of severe disease with either acute respiratory distress syndrome.

  Diagnosis Top

Any child having symptoms as described above irrespective of contact history is a suspect and should be tested for COVID-19. Specific microbiologic diagnosis is made by the rapid antigen test and/or reverse transcription–polymerase chain reaction (RT-PCR).[3] Symptomatic children who test negative for COVID-19 may be retested and should be evaluated for other illnesses. Antibody tests can be done if symptoms are prolonged and the RT-PCR is negative. CT scan is not recommended for routine diagnosis of COVID-19.

Other supportive investigations include a complete blood count and C-reactive protein. Children with severe disease may demonstrate lymphopenia, thrombocytopenia, and high C-reactive protein (CRP).

  Differential Diagnosis Top

The common differentials of COVID-19 include influenza, other respiratory infections and acute gastroenteritis. In the Indian setting, one should keep tropical infections including enteric fever, dengue and malaria.

  Treatment Top

Mild disease

Children should preferably be isolated with parents at home. Symptomatic therapy with paracetamol, nasal saline drops, and antitussives should be given. There is no data to support the use of multivitamins and zinc. Steam inhalation should be discouraged. No investigations including complete blood count (CBC), CRP, D-dimer, or chest X-ray (CXR) are indicated. There is no role of azithromycin, antibiotics, ivermectin, hydroxychloroquine, and favipiravir for treatment. Systemic steroids should not be given. The patient should be monitored for red flag signs including persistent high fever for more than 4–5 days, drowsiness, fast breathing, and drop in saturation below 94%. Children with fever lasting for more than 4–5 days should be investigated with CBC, CRP, CXR, urine routine, and blood culture to assess for severity of disease and to rule out other infections. The patient can be de-isolated 10 days from onset of symptoms, and repeat RT-PCR testing is not indicated.[5]

Children with mild disease and comorbidities should be monitored more carefully and admitted to isolation facilities if needed. The monoclonal antibody cocktail of casirivimab and imdevimab may be administered to some of these children with severe comorbidities who are above the age of 12 years and weight more than 40 kg.

Moderate and severe disease

These children should be hospitalized in dedicated isolation unit. Treatment protocols in children are largely extrapolated from adult studies.[3],[5] Basic investigations including CBC, CRP, CXR, and liver and renal functions should be performed. In children without hypoxia, only hydration, paracetamol, and supportive care are indicated. Antibiotics are not routinely indicated as coinfections at presentation are uncommon. In hypoxic children, oxygen should be initiated with nasal prongs/face mask or nonrebreathing mask as per need. Awake proning should be encouraged. Steroid therapy should be initiated with intravenous dexamethasone 0.15 mg/kg daily. Remdesivir may be offered to children with hypoxia with disease duration <10 days as a loading dose of 5 mg/kg and maintenance dose of 2.5 mg/kg (200 mg and 100 mg in children more than 40 kg) for a total of 5 days. Enoxaparin 1 mg/kg once daily is also indicated. Children with severe hypoxia may need noninvasive ventilation or high-frequency nasal cannula or even endotracheal intubation and ventilation. Children with rapidly progressing respiratory failure with high inflammatory markers despite steroids may be given tocilizumab 4–8 mg/kg single dose. Convalescent plasma is no longer recommended for therapy. Complications of severe disease include secondary bacterial/fungal infections, myocarditis, pulmonary thromboembolism, and barotrauma.

  Prevention Top

Prevention of COVID-19 in children entails COVID appropriate behavior in adults and appropriate use of masks in children aged more than 5 years. While COVID-19 vaccines are being evaluated in children, children are not a priority group for vaccination at present.

  Conclusion Top

Fortunately, COVID-19 is a mild disease in children. The focus should be on testing symptomatic children and isolating them with parents. Symptomatic care suffices for the majority. In children with severe disease, treatment includes oxygen, steroids, anticoagulation, and good supportive care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

UNICEF. COVID-19 information Centre. Available from: https://www.unicef.org/coronavirus/covid-19. [Last accessed on 2021 Jul 18].  Back to cited text no. 1
WHO Unity Seroprevalnce Study of AIIMS. Serological Prevalence of SARS-CoV-2 Antibody Among Children and Young Age (Between Age 2-17 Years) Group in India: An Interim Result from a Large Multi-Centric Population-Based Seroepidemiological Study. Available from: https://www.medrxiv.org/content/10.1101/2021.06.15.21258880v1.full.pdf. [Last accessed on 2021 Jul 18].  Back to cited text no. 2
Borrelli M, Corcione A, Castellano F, Fiori Nastro F, Santamaria F. Coronavirus disease 2019 in children. Front Pediatr 2021;9:668484.  Back to cited text no. 3
Dhochak N, Singhal T, Kabra SK, Lodha R. Pathophysiology of COVID-19: Why children fare better than adults? Indian J Pediatr 2020;87:537-46.  Back to cited text no. 4
Ministry of Health and Family Welfare of India. Guidelines for Management of COVID-19 in Children (Below 18 years). Available from: https://www.mohfw.gov.in/pdf/GuidelinesforManagementofCOVID19inCHILDREN18June2021final.pdf. [Last accessed on 2021 Jul 18].  Back to cited text no. 5


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