What is the first line of treatment for a pediatric patient with a systemic viral infection?

First-Line Treatment for Pediatric Systemic Viral Infections

The first-line treatment for pediatric patients with systemic viral infections is supportive care, including hydration, fever management with antipyretics, and close monitoring for respiratory distress or clinical deterioration. 1, 2, 3

Supportive Care as the Foundation

• Ensure adequate hydration through oral fluids as the primary intervention; intravenous fluids become necessary if oral intake is inadequate or if significant vomiting occurs 1
• Manage fever with age-appropriate doses of acetaminophen or ibuprofen 1
• Monitor continuously for signs of clinical deterioration including increased work of breathing, altered mental status, persistent high fever, or hypoxemia 1, 3
• Provide nasal suctioning for infants with nasal congestion to maintain airway patency 3
• Administer supplemental oxygen only when hypoxemia is documented by pulse oximetry 3, 4

When Specific Antiviral Therapy IS Indicated

Influenza Virus

• Initiate oseltamivir immediately for children with moderate to severe symptoms consistent with influenza, particularly if presenting within 48 hours of symptom onset 5
• Dosing varies by body weight: 30 mg every 12 hours for children <15 kg, 45 mg every 12 hours for 15-23 kg, and 75 mg every 12 hours for >24 kg 5
• Treatment should not be delayed while awaiting laboratory confirmation if clinical suspicion is high during local influenza circulation 6

Herpes Simplex Virus (HSV) or Varicella-Zoster Virus (VZV)

• Start intravenous aciclovir immediately if HSV or VZV encephalitis is suspected, without waiting for diagnostic confirmation 6, 1
• Dosing for children 3 months-12 years: 500 mg/m² every 8 hours 6
• Dosing for children >12 years: 10 mg/kg every 8 hours 6
• Continue treatment for 14-21 days for proven HSV encephalitis, with children aged 3 months-12 years receiving a minimum of 21 days 6

Respiratory Syncytial Virus (RSV)

• Ribavirin inhalation is indicated only for hospitalized infants and young children with severe lower respiratory tract infection due to RSV, particularly those with underlying conditions such as prematurity, immunosuppression, or cardiopulmonary disease 7
• Treatment is most effective when instituted within the first 3 days of clinical illness 7
• RSV infection must be documented by rapid diagnostic methods before continuing treatment beyond initial empiric therapy 7

COVID-19 with Hyperinflammation

• Glucocorticoids (dexamethasone) should be used as first-tier immunomodulatory treatment in pediatric patients with severe COVID-19 manifesting as acute respiratory distress syndrome, shock, or signs of hyperinflammation 6
• This recommendation is based on the RECOVERY trial demonstrating significant mortality reduction in patients requiring mechanical ventilation 6
• Consider anakinra for refractory disease despite glucocorticoid administration or for patients with contraindications to steroids 6

What NOT to Do: Common Pitfalls

• Do NOT routinely prescribe antibiotics for viral infections without evidence of bacterial superinfection 1, 3
• Do NOT use bronchodilators or systemic corticosteroids routinely in infants and children ages 1-23 months with bronchiolitis 3
• Do NOT order routine chest x-rays or blood tests for children with bronchiolitis or pneumonia who are well enough for outpatient management 3
• Do NOT use empirical antiviral treatment for all patients with encephalopathy without regard to likely diagnosis, as this practice is not beneficial and can delay identification of other treatable etiologies 6

Indications for Hospital Admission

• Signs of respiratory distress: markedly raised respiratory rate, grunting, intercostal recession, or breathlessness with chest signs 1
• Cyanosis or hypoxia requiring oxygen supplementation 1
• Severe dehydration or inability to maintain adequate oral intake 1
• Altered level of consciousness or complicated seizures 1
• Signs of septicemia including extreme pallor, hypotension, or floppiness in infants 1

Special Considerations for Secondary Bacterial Infection

• For children with persistent fever who become clinically unstable, consider secondary bacterial infection and broaden antimicrobial coverage 6, 1
• Children with influenza or RSV requiring intensive care are at higher risk for secondary bacterial infections 1
• Co-amoxiclav is the drug of choice for children <12 years with suspected bacterial co-infection 1
• For penicillin-allergic children, use clarithromycin or cefuroxime 1