What is the recommended treatment for a 5-year-old patient diagnosed with COVID-19?

Treatment of COVID-19 in a 5-Year-Old Child

For a 5-year-old with COVID-19, supportive care is the primary treatment approach, with specific interventions reserved for those at high risk of progression or with severe disease. 1, 2

Initial Assessment and Risk Stratification

Determine disease severity immediately to guide treatment decisions:

• Mild disease (most common in children): Fever, cough, fatigue without respiratory distress 3, 2
• Moderate disease: Evidence of lower respiratory tract involvement but oxygen saturation ≥94% 2
• Severe disease: Oxygen saturation <94%, respiratory distress, or multiorgan involvement 2, 4
• Critical disease: Respiratory failure requiring mechanical ventilation, shock, or multiorgan failure 4

Key clinical features to monitor: Fever (most common symptom at 44.4%), cough (28.6%), and shortness of breath (26.6%) 5. In children, atypical presentations may include "COVID toes," anosmia, or croup 2.

Treatment by Disease Severity

Mild to Moderate Disease (Majority of Cases)

Provide supportive care only for most children with mild-to-moderate COVID-19:

• Antipyretics: Use paracetamol (acetaminophen) for fever and discomfort; continue only while symptoms persist 3. Paracetamol is preferred over NSAIDs until more evidence is available 3.
• Hydration: Encourage regular fluid intake to avoid dehydration, but no more than 2 liters per day 3
• Cough management: For children over 1 year old, honey can be used as a simple first-line measure 3
• Supplemental vitamins: Zinc, vitamin D, and vitamin C may be provided as supportive measures 5

Do NOT use corticosteroids in patients not requiring supplemental oxygen, as this causes harm without benefit 1.

High-Risk Outpatients Requiring Antiviral Therapy

Consider antiviral therapy within 7 days of symptom onset for children at high risk of progression to severe disease 1, 6:

• Remdesivir is the only FDA-approved antiviral for children as young as birth (weighing at least 1.5 kg) 6
• Dosing for 5-year-old children (typically weighing 15-25 kg):
  • Loading dose: 5 mg/kg IV on Day 1
  • Maintenance dose: 2.5 mg/kg IV once daily from Day 2
  • Total duration: 3 days for non-hospitalized patients at high risk 6
• Initiate treatment as soon as possible after diagnosis and within 7 days of symptom onset 1, 6

High-risk factors include congenital anomalies, lung disease, immunosuppression, or other significant comorbidities 5.

Severe to Critical Disease (Hospitalized with Oxygen Requirement)

For children requiring supplemental oxygen, implement the following:

1. Dexamethasone 6 mg daily for 10 days (or weight-based equivalent: 0.15 mg/kg/day) reduces mortality 1, 4
2. Remdesivir:
   • Loading dose: 5 mg/kg IV on Day 1
   • Maintenance: 2.5 mg/kg IV once daily from Day 2
   • Duration: 5 days for those not on mechanical ventilation; 10 days for those requiring invasive mechanical ventilation or ECMO 6
3. Prophylactic anticoagulation for all hospitalized patients 1
4. Prone positioning for patients on mechanical ventilation 1

Do NOT use remdesivir in mechanically ventilated patients, as it has no survival benefit in this population 1.

Multisystem Inflammatory Syndrome in Children (MIS-C)

Be vigilant for MIS-C, which presents 2-6 weeks after acute infection:

• Classic presentation: Fever (100% of cases), rash (53.9%), and multiorgan involvement 5, 3
• First-line treatment: IVIG 2 gm/kg as a single dose PLUS glucocorticoids (methylprednisolone 0.8 mg/kg/day or equivalent) 3, 4
• Antiplatelet therapy: Low-dose aspirin (3-5 mg/kg/day, maximum 81 mg/day) until platelet count normalizes and coronary arteries confirmed normal at ≥4 weeks 3
• Cardiac monitoring: Obtain echocardiogram and ECG at presentation and every 48 hours while hospitalized 3

Critical Laboratory Monitoring

Obtain baseline and serial monitoring of inflammatory markers in severe cases:

• Elevated markers predicting severe disease: ESR, CRP, D-dimer, LDH, IL-6, ferritin, and procalcitonin 5
• Procalcitonin elevation is a specific risk factor for severe disease 5
• Perform hepatic laboratory testing before starting remdesivir and monitor during treatment 6
• Monitor prothrombin time before and during remdesivir therapy 6

Common Pitfalls to Avoid

1. Never use corticosteroids in non-hypoxic patients – this causes harm 1
2. Do not delay antiviral therapy in high-risk patients – initiate within 7 days of symptom onset 1, 6
3. Avoid routine antibiotic use – only 71.7% of hospitalized children received antibiotics, often unnecessarily 5
4. Do not use remdesivir in mechanically ventilated patients – no survival benefit 1
5. Monitor for MIS-C even after recovery from acute infection – can occur 2-6 weeks later 3

Follow-Up and Monitoring

Ensure close clinical follow-up for all children:

• Outpatients: Monitor for worsening symptoms, particularly respiratory distress 3
• Post-discharge: Screen for long COVID symptoms and MIS-C 2
• Cardiac follow-up: For those with MIS-C or severe disease, obtain cardiac MRI at 2-6 months post-illness 3