At what age can COVID-19 (Coronavirus Disease 2019) treatment be initiated in patients?

COVID-19 Treatment in Pediatric Patients

COVID-19 treatment can be initiated in patients from birth onwards, provided they weigh at least 1.5 kg, as indicated by the FDA-approved remdesivir label for pediatric patients.

Age-Based Treatment Guidelines

The FDA has specifically approved remdesivir (VEKLURY) for COVID-19 treatment in:

• Adults
• Pediatric patients from birth to less than 18 years of age weighing at least 1.5 kg 1

This applies to patients who are either:

• Hospitalized, or
• Not hospitalized with mild-to-moderate COVID-19 but at high risk for progression to severe disease

Dosing for Pediatric Patients

For pediatric patients, dosing is weight-based:

1. Patients weighing 1.5 kg to less than 3 kg and at least 28 days old:

   • Loading dose: 5 mg/kg on Day 1
   • Maintenance dose: 2.5 mg/kg once daily from Day 2

2. Patients less than 28 days old and at least 1.5 kg:

   • Loading dose: 2.5 mg/kg on Day 1
   • Maintenance dose: 1.25 mg/kg once daily from Day 2

3. Patients weighing 3 kg to less than 40 kg and at least 28 days old:

   • Loading dose: 5 mg/kg on Day 1
   • Maintenance dose: 2.5 mg/kg once daily from Day 2

4. Patients weighing at least 40 kg:

   • Loading dose: 200 mg on Day 1
   • Maintenance dose: 100 mg once daily from Day 2 1

Special Considerations for Pediatric COVID-19

Disease Presentation

• The prevalence of COVID-19 is lower in children than adults
• Between 10-90% of pediatric COVID-19 cases are asymptomatic 2
• Symptomatic cases typically present with mild symptoms including cough, fever, and sore throat
• Intensive care admission and mortality are rare in children 2

Risk Factors for Severe Disease

Children with the following conditions require closer monitoring as they may have more severe disease:

• Children under 5 years of age (particularly those under 28 days)
• Underlying cardiovascular disease
• Respiratory system diseases
• Other comorbidities 3

Multisystem Inflammatory Syndrome in Children (MIS-C)

For children presenting with MIS-C, a different treatment approach is recommended:

• IVIG (81% of cases)
• Aspirin (67% of cases)
• Corticosteroids (64% of cases)
• Inotropes (62% of cases)
• Anticoagulation (56% of cases, mostly LMWH) 4

Treatment Algorithm for Pediatric COVID-19

1. For mild cases (majority of pediatric patients):

   • Supportive care only
   • Monitor for symptom progression

2. For moderate to severe cases:

   • Remdesivir (as per FDA-approved dosing)
   • Consider corticosteroids for those with respiratory support requirements

3. For critical cases:

   • Remdesivir
   • Dexamethasone
   • Consider immunomodulatory agents (tocilizumab, baricitinib) 5

Important Precautions

• Perform hepatic laboratory testing in all patients before starting remdesivir and during treatment
• Determine prothrombin time before starting and monitor during treatment
• Administer remdesivir only in settings where healthcare providers have immediate access to medications to treat severe infusion or hypersensitivity reactions 1

Treatment Duration

• For hospitalized patients requiring invasive mechanical ventilation and/or ECMO: 10 days
• For hospitalized patients not requiring invasive mechanical ventilation and/or ECMO: 5 days
• If no clinical improvement is observed, treatment may be extended for up to 5 additional days (maximum 10 days total) 1

Remember that COVID-19 treatment should be initiated as soon as possible after diagnosis of symptomatic COVID-19, regardless of age, provided the patient meets the minimum weight requirement of 1.5 kg.