Doctors urged to read living guidelines for kids with COVID-19

DOCTORS are being urged to familiarise themselves with new “living” guidelines for the clinical care of children and adolescents with COVID-19 in anticipation of rising paediatric cases as restrictions ease and borders open.

New consensus guidelines from the Paediatric and Adolescent Care Panel of the Australian Living Evidence Consortium have been released and will be updated in near real-time at www.covid19evidence.net.au. A guideline summary has also been published in the MJA.

Guidelines co-author, Associate Professor Asha Bowen, Program Head of Vaccines and Infectious Diseases at the Telethon Kids Institute in Perth, told InSight+ that the guidelines were designed to be useful no matter how far away a patient and their doctor might live and work from a paediatric intensive care unit.

“We [have] nuanced the advice to make sure that wherever you are in Australia, there’s information available to you either to use with your own clinical care or to contact experts and find information that’s needed for the child in front of you,” Associate Professor Bowen said, in an exclusive podcast.

COVID-19 was “on the whole … not a disease of childhood”, she stressed, saying parents should be reassured about the safety of sending children back to school with appropriate safeguards.

Yet new therapeutic guidelines were needed, she added, to help ensure that the few children who do get severe disease are able to access expert-level care.

“I think with the international borders opening we will see probably more cases of COVID-19,” Associate Professor Bowen said. “I do think we need to now start thinking about what that’s going to look like, both for kids and also hospital level health care on the whole, and how we’re going to move forward.”

According to the guidelines, over 25 000 children aged 0–18 years have been infected with COVID-19 in Australia to date — a quarter of all cases — with one death reported.

Guidelines co-author, Dr Brendan McMullan, a paediatric infectious diseases specialist with Sydney Children’s Hospital and UNSW Sydney, said Australia had excellent testing and data capture on the number of children with infection, whereas many other countries only measured and reported on the most severe cases.

“Of the children we’ve looked after in NSW with COVID-19 … almost all of them have been able to stay at home,” he said.

“The progression to severe disease from COVID-19, while it can occur in children, has mainly occurred in teenagers rather than younger children, and even in teenagers it is much less common than older adults [in Australia].”

The guidelines provide detailed advice on identifying paediatric inflammatory multisystem syndrome (PIMS-TS or MIS-C)— a paediatric form of Kawasaki disease that can follow COVID-19 infection.

Defining features of the condition are persistent fever lasting 3 or 4 days, with other signs of inflammation such as conjunctivitis, red cracked lips, swollen hands and feet, a rash, and abdominal pain.

Children and adolescents who have suspected or confirmed PIMS-TS should be urgently managed by and discussed with a multidisciplinary team, the guidelines state.

The guidelines recommend corticosteroids as first line treatment for acute COVID-19 in children and adolescents who require oxygen.

They also say tocilizumab could be considered, but remdesivir should not be administered routinely in this population.

NSW GP, Dr James Best, another member of the guidelines panel, said one interesting recommendation for GPs was the use of inhaled budesonide for symptomatic COVID-19 in children and adolescents who do not require oxygen and have one or more risk factors for disease progression, such as severe asthma or obesity.

“The use of budesonide — a conditional recommendation — is something that may be relevant to some children being managed in the community,” he said.

The full guidelines also recommend that sotrovimab could be considered in exceptional circumstances for children aged 12 years and over and weighing at least 40 kg with mild COVID-19 and at high risk of deterioration.

Dr Best said: “In the right populations, evidence suggests sotrovimab significantly reduces the risk of disease progression.”

Many of the guidelines’ recommendations are based on extrapolations from trials in adults with COVID-19.

Dr Best commented: “The amount of data available on disease-modifying treatments for COVID-19 in children is very limited, but that’s going to be changing with time.

“The guidelines are a living document,” he added. “There are all sorts of things on the horizon, so watch this space.”

Associate Professor Bowen said she had reasonable hopes that a vaccine program for children aged 5–12 years would commence in Australia by early 2022.

Dr Greg Kelly, a paediatric intensive care specialist and member of the new OzSAGE advisory group welcomed the guidelines.

“They are well written, though of course fairly broad, and allow substantial scope for tailoring treatments to the patient’s need,” he said.

Yet, having worked for the Royal Flying Doctor Service, Dr Kelly expressed concerns that in remote areas, children with severe COVID-19 might not be able to access the care they needed.

“At night, in an area of over 1 million km² in the Northern Territory, there is one plane, one pilot, one doctor and one nurse available to transport critically ill people who need higher levels of care, and so just one sick patient can make transport for another sick patient literally impossible until morning,” he said.

“Far and away, the best thing we can do to protect ourselves, our community and the health system is to protect ourselves from COVID-19,” Dr Kelly said. “Get vaccinated, follow the public health measures, take this really seriously and continue to do a great job in Australia where we avoid the worst of what most other places have seen.”

The new guidelines note that children from minority ethnic groups and those with comorbidities appear to be disproportionately affected by COVID-19, based on data from the UK and the US.

Guidelines co-author, Dr Lorraine Anderson is medical director for the Kimberley Aboriginal Medical Services in Broome. She told InSight+:

“We are very concerned about infection in all Kimberley residents, as we have a low rate of vaccination and a high rate of chronic disease.

“Aboriginal children have a higher rate of chronic disease also – asthma, rheumatic heart disease and renal disease —which could potentially see them more susceptible to becoming sick with COVID-19,” she added.

Dr Anderson said she believed there was good intention from the Commonwealth and the states to ensure children in remote areas had access to the testing, treatment and care they require in the face of an outbreak.