What is the management approach for a 10-month-old patient with COVID-19 (Coronavirus disease 2019)?

Management of COVID-19 in a 10-Month-Old Infant

For a 10-month-old with COVID-19, provide supportive care with close monitoring of vital signs (heart rate, respiratory rate, SpO2) in a quarantined setting, as most infants have mild disease that improves without specific antiviral therapy. 1

Initial Assessment and Risk Stratification

Monitor for clinical features indicating severe disease:

• Persistent fever >38°C despite supportive measures 2
• Respiratory distress (tachypnea, retractions, grunting, nasal flaring) 1, 3
• Oxygen saturation <90% on room air 1
• Poor feeding, lethargy, or altered mental status 3
• Signs of dehydration or hemodynamic instability 1

Key laboratory markers if hospitalization required:

• Elevated creatine kinase (CK), CK-MB, and lactate dehydrogenase (LDH) suggest multi-systemic involvement 3
• D-dimer levels to assess thrombosis risk 4
• Hepatic function tests before considering any antiviral therapy 5

Management Based on Disease Severity

Mild/Asymptomatic Disease (Most Common)

Outpatient management is appropriate for most infants: 1

• Isolate in well-ventilated room with caregiver wearing N95 or surgical mask 2
• Monitor vital signs including temperature, heart rate, respiratory rate, and SpO2 regularly 1, 2
• Ensure adequate hydration and nutrition 1
• Paracetamol (acetaminophen) preferred over NSAIDs for fever management 6
• Continue breastfeeding if mother is COVID-19 positive, with mother wearing surgical mask 1, 7

Caregiver should be healthy without underlying diseases when possible 2

Moderate Disease (Requiring Hospitalization)

Admit to hospital if: 2

• Persistent high fever despite antipyretics 2
• Development of dyspnea or respiratory distress 2
• Inability to maintain adequate oral intake 1
• Presence of comorbidities with clinical deterioration 2

Hospital management includes: 1

• Quarantined ward with close vital sign monitoring 1
• Supplemental oxygen via nasal cannula or mask if SpO2 <90%, adjusting flow to maintain SpO2 ≥90% 1, 2
• High-flow nasal cannula (HFNC) or non-invasive CPAP for acute hypoxemic respiratory failure without immediate indication for mechanical ventilation 1, 7
• Supportive care with IV fluids if needed 1

Severe Disease (Requiring Intensive Care)

Consider ICU admission for: 1

• Severe acute respiratory infection (SARI) requiring invasive mechanical ventilation 1
• Multiorgan failure 1
• Hemodynamic instability requiring vasopressors 1

ICU management: 1

• Intubation by most experienced operator with full PPE, minimizing bag-mask ventilation 1
• Limit tidal volumes ≤6 mL/kg predicted body weight and plateau pressure ≤30 cm H2O for ARDS 1
• Closed airway suction system to reduce viral aerosol production 1

Pharmacologic Therapy

Antiviral Therapy

Remdesivir is the only FDA-approved antiviral for infants ≥1.5 kg: 5

• For infants weighing 1.5 kg to <3 kg (at least 28 days old): Loading dose 2.5 mg/kg IV on Day 1, then 1.25 mg/kg IV once daily from Day 2 5
• For infants weighing 3 kg to <40 kg (at least 28 days old): Loading dose 5 mg/kg IV on Day 1, then 2.5 mg/kg IV once daily from Day 2 5
• Treatment duration: 5 days for non-ventilated patients; up to 10 days for those requiring mechanical ventilation/ECMO 5
• Remdesivir should be considered in hospitalized infants at high risk for progression to severe disease 7, 4, 8
• Perform hepatic laboratory testing before starting and monitor during treatment 5

Corticosteroids

Do NOT routinely administer corticosteroids unless the infant requires supplemental oxygen or ventilatory support: 1

• Corticosteroids are recommended ONLY for patients requiring oxygen, non-invasive ventilation, or mechanical ventilation 1
• Strong recommendation AGAINST corticosteroids in hospitalized patients not requiring supplementary oxygen 1
• Studies on influenza found corticosteroids exacerbate infection and increase mortality rates 1

Antibiotics

Do NOT routinely prescribe antibiotics for COVID-19: 1

• Consider antibiotics only if bacterial superinfection (healthcare-associated pneumonia, ventilator-associated pneumonia) cannot be ruled out 1, 6
• Bacterial coinfection occurs in approximately 40% of viral respiratory infections requiring hospitalization 6

Other Medications to AVOID

The following are NOT recommended for pediatric COVID-19: 1

• Hydroxychloroquine (strong recommendation against) 1
• Azithromycin (without bacterial infection) 1
• Lopinavir-ritonavir (strong recommendation against) 1
• Interferon-β 1
• Colchicine 1

Infection Control Measures

Strict isolation protocols: 2

• Infant should wear medical mask when caregivers present (if tolerated) 2
• Caregivers must wear N95 masks (preferred) or surgical masks 2
• Clean and disinfect hands before/after contact with infant, before leaving room, before/after feeding 2
• Use 500 mg/L chlorine-containing disinfectant for environmental cleaning daily 2
• Avoid sharing personal items (bottles, pacifiers, toys) 2

Discharge Criteria

Infant may be discharged when: 2

• Body temperature normal for >3 days 2
• Respiratory symptoms significantly improved 2
• Two consecutive negative respiratory PCR tests at least one day apart 2

Common Pitfalls to Avoid

• Do not delay supportive care while awaiting test results - begin monitoring and isolation immediately with suspected infection 1
• Do not use corticosteroids in mild disease - they provide no benefit and may cause harm 1
• Do not routinely prescribe antivirals or antibiotics - reserve for specific indications only 1
• Do not separate breastfeeding mother from infant - benefits of breastfeeding outweigh transmission risk with proper precautions 1, 7
• Do not use NSAIDs as first-line antipyretics - paracetamol is preferred until more evidence available 6