What is the appropriate management for a 7-month-old male infant with a positive Covid-19 test, presenting with fever, tachycardia, and borderline oxygen saturation?

Management of COVID-19 in a 7-Month-Old Infant

This 7-month-old infant with confirmed COVID-19, fever, tachycardia, and borderline oxygen saturation requires hospital admission for close monitoring and supportive care, as infants under 12 months are at higher risk for severe disease progression. 1, 2

Immediate Assessment and Monitoring

Admit the infant for observation with continuous monitoring of vital signs including heart rate, respiratory rate, and oxygen saturation. 1 While most infants with COVID-19 have mild disease, those under 6 months are at increased risk for deterioration, and borderline oxygen saturation warrants inpatient management. 3, 2

Key monitoring parameters include:

• Continuous pulse oximetry with intervention if SpO2 falls below 92% 1, 2
• Respiratory rate assessment (normal for 7 months is <50 breaths/min) 1
• Signs of respiratory distress including nasal flaring, retractions, or grunting 1
• Cardiovascular status given the tachycardia 1

Laboratory and Diagnostic Evaluation

Obtain baseline laboratory studies including complete blood count, C-reactive protein, and consider chest imaging if respiratory symptoms worsen. 1 Common findings in hospitalized pediatric COVID-19 patients include lymphopenia, leukopenia, and elevated inflammatory markers. 1, 2

Monitor for signs of Multisystem Inflammatory Syndrome in Children (MIS-C), though this typically presents 2-6 weeks after acute infection rather than during the acute phase. 4, 5 The current presentation is consistent with acute COVID-19 rather than MIS-C. 4

Supportive Management

Fever Management

Administer acetaminophen 10-15 mg/kg every 4-6 hours as first-line therapy for fever control. 4 If fever persists despite acetaminophen, ibuprofen 10 mg/kg every 6-8 hours can be added. 4 Antipyretics provide symptom relief but do not prevent febrile seizures. 4

Oxygen Support

Provide supplemental oxygen if SpO2 falls below 92%. 1, 2 Start with low-flow nasal cannula and escalate to high-flow nasal cannula if needed. 1 For severe respiratory distress requiring mechanical ventilation, use low tidal volumes (5-6 mL/kg), adequate PEEP, and consider prone positioning. 2

Hydration and Nutrition

Ensure adequate hydration and maintain normal feeding if the infant tolerates oral intake. 1 Monitor for signs of dehydration including decreased urine output and poor feeding. 5

Antiviral Therapy Consideration

Remdesivir may be considered for this infant if there is clinical deterioration or high risk for progression to severe disease. 6, 7, 8 The FDA-approved dosing for infants weighing 1.5 kg to less than 3 kg who are at least 28 days old is:

• Loading dose: 2.5 mg/kg IV on Day 1
• Maintenance dose: 1.25 mg/kg IV once daily from Day 2 6

For infants 3 kg to less than 40 kg who are at least 28 days old:

• Loading dose: 5 mg/kg IV on Day 1
• Maintenance dose: 2.5 mg/kg IV once daily from Day 2 6

The recommended treatment duration is 5 days for hospitalized patients not requiring mechanical ventilation, extendable to 10 days if no clinical improvement occurs. 6

Medications to Avoid

Do not routinely administer corticosteroids, antibiotics, or other antivirals unless specifically indicated. 1 Corticosteroids are not recommended for mild-to-moderate COVID-19 in children and should be reserved for severe disease with respiratory failure or MIS-C. 1, 7 Antibiotics should only be used if bacterial co-infection or superinfection is suspected based on clinical and laboratory findings. 1

Discharge Criteria and Follow-Up

The infant can be discharged when:

• Fever has resolved for at least 24 hours without antipyretics 3
• Oxygen saturation remains stable above 92% on room air 1
• Respiratory status is stable without distress 3
• Adequate oral intake is maintained 3

Arrange close outpatient follow-up within 24-48 hours after discharge. 4 Instruct parents to return immediately for worsening respiratory distress, persistent high fever, altered mental status, poor feeding, decreased urine output, or signs of cardiovascular compromise. 4, 5

Monitor for development of MIS-C over the subsequent 2-6 weeks, which presents with persistent fever, multiorgan dysfunction, and elevated inflammatory markers. 4, 5 Reassure parents that the overall prognosis for healthy infants with COVID-19 is excellent, with most recovering completely without complications. 4, 3

Special Considerations

Infants under 12 months represent a higher-risk group for severe COVID-19 compared to older children, warranting a lower threshold for hospitalization and closer monitoring. 2 However, recent data from the Omicron era suggests that COVID-19 in young healthy infants is typically mild with no major complications in the majority of cases. 3

Ensure appropriate infection control measures including isolation precautions and proper PPE use by healthcare providers. 1 Parents should wear surgical masks when caring for the infant. 1