What is the treatment approach for Covid-19 in infants?

Treatment Approach for COVID-19 in Infants

For infants with COVID-19, supportive care is the mainstay of treatment, with close monitoring of vital signs and respiratory status, as most cases are mild and self-limiting without requiring specific antiviral therapy.

Clinical Presentation and Assessment

• COVID-19 in infants typically presents as a mild illness with minimal complications, especially in the Omicron variant era 1
• Common symptoms include fever, cough, and mild respiratory symptoms; some infants may be completely asymptomatic 2, 3
• Laboratory findings may show multi-systemic involvement with elevated creatine kinase (CK), creatine kinase-myocardial band (CK-MB), and lactate dehydrogenase (LDH) levels 4
• Between 10-90% of pediatric COVID-19 cases may be asymptomatic, making diagnosis challenging 2

Treatment Recommendations for Asymptomatic and Mild Cases

• For asymptomatic neonates and young infants with suspected COVID-19 infection, monitoring and supportive care in a quarantined setting are essential 5
• Vital observations including heart rate, respiration rate, and SpO2 should be closely monitored 5
• Neonatal feeding should be continued if the mother is COVID-19 positive 5
• Hospitalization may not be necessary for well-appearing infants with COVID-19 as long as their clinical and laboratory evaluations do not raise concerns 1

Management of Symptomatic Cases

• For symptomatic neonates, medical management and supportive interventions are necessary 5
• Supportive care remains the cornerstone of management, as there is currently no specific treatment for COVID-19 in infants 2, 6
• The average duration of hospitalization for infants with COVID-19 is typically short (approximately 1.3 ± 0.7 days) 1
• Intensive care may be required in a subset of cases (approximately 28.6%), particularly in preterm infants 4

Respiratory Support

• Respiratory support should be provided based on the severity of respiratory symptoms:
  • Low-flow nasal cannula for mild respiratory distress 5
  • High-flow nasal cannula for moderate respiratory distress 5
  • Non-invasive ventilation may be required in some cases 4
  • Invasive ventilation with intratracheal surfactant instillation is rarely needed but may be necessary in severe cases 4

Medication Considerations

• Antiviral therapy:

  • Remdesivir may be considered for severe cases in infants weighing at least 1.5 kg 7
  • For infants less than 28 days old and at least 1.5 kg: loading dose of 2.5 mg/kg on Day 1, followed by 1.25 mg/kg once daily from Day 2 7
  • For infants at least 28 days old and 1.5 kg to less than 3 kg: loading dose of 5 mg/kg on Day 1, followed by 2.5 mg/kg once daily from Day 2 7
  • Treatment should be initiated as soon as possible after diagnosis 7

• Antibiotics:

  • Not routinely recommended unless there is evidence of bacterial co-infection or superinfection 5
  • Consider possible healthcare-associated pneumonia or other nosocomial infections when evaluating for co-infections 5

• Corticosteroids:

  • Not routinely recommended for viral pneumonia in infants with COVID-19 5
  • Their use in studies on influenza has been found to exacerbate infection and increase mortality rates 5

Special Considerations for Multisystem Inflammatory Syndrome in Children (MIS-C)

• MIS-C is a rare but severe complication that can occur in children with COVID-19 2
• For MIS-C treatment, consider:
  • Intravenous immunoglobulin (IVIG) and/or glucocorticoids as first-tier agents 5
  • Low-dose aspirin (3–5 mg/kg/day; maximum 81 mg/day) for patients with MIS-C and Kawasaki disease-like features and/or thrombocytosis 5
  • Anticoagulation therapy for documented thrombosis or ejection fraction <35% 5

Monitoring and Follow-up

• Close monitoring of cardiac function is essential, especially in cases with MIS-C or myocardial involvement 5
• Repeat echocardiograms should be obtained at 7–14 days and 4–6 weeks after initial presentation in cases with cardiac involvement 5
• EKG should be performed at a minimum of every 48 hours in hospitalized patients with cardiac involvement 5

Prognosis

• Most infants with COVID-19 improve with supportive care and are successfully discharged 4
• Mortality is rare in the pediatric population, including infants 2
• Long-term respiratory and developmental implications remain unknown and require further research 3