What treatment options are available for Covid-19 in children?

Treatment Options for COVID-19 in Children

Yes, there are specific drug treatments available for COVID-19 in children, with remdesivir being the only FDA-approved antiviral medication for pediatric patients, and additional therapies including Paxlovid for high-risk children and immunomodulatory agents for severe disease or MIS-C.

FDA-Approved Antiviral Treatment

Remdesivir (Veklury) is FDA-approved for children with COVID-19 from birth (weighing at least 1.5 kg) to less than 18 years of age 1:

Dosing by Weight Category

• Infants <28 days old and ≥1.5 kg: 2.5 mg/kg loading dose on Day 1, then 1.25 mg/kg once daily 1
• Infants ≥28 days old weighing 1.5 kg to <3 kg: 2.5 mg/kg loading dose on Day 1, then 1.25 mg/kg once daily 1
• Children ≥28 days old weighing 3 kg to <40 kg: 5 mg/kg loading dose on Day 1, then 2.5 mg/kg once daily 1
• Children weighing ≥40 kg: 200 mg loading dose on Day 1, then 100 mg once daily 1

Treatment Duration

• 5 days for hospitalized patients not requiring mechanical ventilation/ECMO 1
• Up to 10 days for patients requiring invasive mechanical ventilation and/or ECMO 1
• Treatment should be initiated as soon as possible after diagnosis 1

Oral Antiviral for High-Risk Outpatients

Paxlovid (nirmatrelvir/ritonavir) is recommended for high-risk children with COVID-19 2:

High-Risk Features Warranting Treatment

• Congenital heart disease 2
• Chronic lung disease 2
• Neurological disorders 2
• Obesity 2
• Diabetes mellitus 2

Treatment for Multisystem Inflammatory Syndrome in Children (MIS-C)

For children who develop MIS-C, a distinct post-infectious complication, first-line therapy consists of IVIG and/or glucocorticoids 3:

First-Tier Immunomodulatory Therapy

• High-dose IVIG: 1-2 gm/kg (assess cardiac function and fluid status before administration) 3
• Glucocorticoids: Low-to-moderate doses for standard cases; high-dose IV pulse glucocorticoids for life-threatening complications such as shock requiring multiple inotropes/vasopressors 3
• Stepwise progression should be used if first-tier treatments fail 3

Second-Tier Therapy

• Anakinra (IV or subcutaneous) may be considered for MIS-C refractory to IVIG and glucocorticoids 3

Antiplatelet and Anticoagulation Therapy

• Low-dose aspirin (3-5 mg/kg/day up to 81 mg once daily) for all MIS-C patients until platelet count normalizes and normal coronary arteries confirmed at ≥4 weeks 3
• Anticoagulation with enoxaparin or warfarin for coronary artery z-score >10.0 3
• Anticoagulation therapy for moderate or severe left ventricular dysfunction (ejection fraction <35%) 3, 2, 4

Treatment for Severe COVID-19 with Hyperinflammation

For children with severe acute COVID-19 manifesting as ARDS, shock, or hyperinflammation, immunomodulatory therapy should be considered in addition to remdesivir 3:

Glucocorticoids for Severe Disease

• Dexamethasone is recommended for children with respiratory distress requiring oxygen or ventilatory support 3, 5, 6
• Glucocorticoids may be associated with worse outcomes if given early or at high doses before severe disease develops 3

IL-6 and IL-1 Inhibitors

• Tocilizumab may be considered for severe COVID-19 with hyperinflammation 3
• Anakinra is favored by expert consensus for pediatric patients with hyperinflammation and severe symptoms 3

Thromboprophylaxis in Hospitalized Children

Anticoagulant thromboprophylaxis should be considered in hospitalized children with COVID-19 meeting specific criteria 2:

Indications for Thromboprophylaxis

• D-dimer ≥5 times upper limit of normal OR presence of clinical VTE risk factors 2
• Risk factors include: central venous catheter, mechanical ventilation, immobility, obesity, active malignancy 2
• Target anti-Xa level: 0.2-0.5 U/mL for LMWH subcutaneously twice daily 2

Supportive Care Remains the Cornerstone

Most children with COVID-19 require only supportive care, as the majority present with mild symptoms 7, 5, 8, 9:

• Fever and cough are the most common presentations 7
• Antipyretics may be used for symptom management 6
• Antibiotics are not routinely recommended unless bacterial co-infection is suspected 4

Important Caveats

• Corticosteroids are NOT routinely recommended for viral pneumonia in infants without respiratory distress, as studies in influenza showed increased mortality 4
• Concomitant use of remdesivir with chloroquine or hydroxychloroquine is not recommended due to potential antagonism 1
• Hepatic laboratory testing and prothrombin time should be performed before starting and during remdesivir treatment 1
• Children with pre-existing rheumatic diseases on immunosuppression do not appear to have increased risk of severe COVID-19, and TNF inhibitors may actually be protective 3