What is the appropriate evaluation and management for an 8‑month‑old infant with possible COVID‑19 exposure or symptoms?

Evaluation and Management of COVID-19 in an 8-Month-Old Infant

For an 8-month-old with suspected COVID-19, provide supportive care at home with close monitoring if the infant is well-appearing with stable vital signs, but immediately seek hospital evaluation if any red flags develop including abnormal vital signs, respiratory distress, altered mental status, poor feeding, or signs of dehydration. 1

Initial Assessment and Risk Stratification

Clinical Presentation to Assess

• Fever and respiratory symptoms are the most common presentations, with fever occurring in 47.5% and cough in 41.5% of pediatric COVID-19 cases 1
• Nasal congestion and runny nose occur in 11.2% of cases 1
• Gastrointestinal symptoms (diarrhea, vomiting) may occur with or without respiratory symptoms 1
• Fatigue is present in 38.5% of cases and independently predicts severe disease 1

Red Flags Requiring Immediate Hospital Evaluation

Admit to the hospital immediately if any of the following are present: 2, 1

• Abnormal vital signs (tachycardia, tachypnea)
• Any degree of respiratory distress
• Oxygen saturation ≤93% 1
• Neurologic deficits or altered mental status
• Poor feeding or signs of dehydration
• Respiratory rate ≥30/min (adjusted for age) 1

Outpatient Management for Well-Appearing Infants

Supportive Care Measures

For asymptomatic or mildly symptomatic infants, provide monitoring and supportive care in a quarantined setting including vital sign monitoring (heart rate, respiratory rate, SpO2) and continuation of normal feeding 3

When Antibiotics Are NOT Indicated

• Do not routinely prescribe antibiotics unless there is clear evidence of bacterial co-infection or superinfection 3
• Do not use corticosteroids routinely for viral pneumonia in infants with COVID-19, as studies in influenza have shown they exacerbate infection and increase mortality 3

Follow-Up Monitoring

• Ensure close clinical follow-up can be maintained if managing outpatient 2
• Instruct caregivers on warning signs requiring immediate medical attention

When to Consider MIS-C (Multisystem Inflammatory Syndrome in Children)

Timing and Clinical Features

Consider MIS-C if the infant develops persistent fever 2-6 weeks after known or suspected SARS-CoV-2 exposure with any of the following features: 2, 1

• Rash (polymorphic, maculopapular, or petechial)
• Gastrointestinal symptoms (diarrhea, abdominal pain, vomiting)
• Oral mucosal changes (red/cracked lips, strawberry tongue)
• Bilateral conjunctivitis without exudate
• Neurologic symptoms

Initial Screening for MIS-C (Tier 1)

If MIS-C is suspected, obtain the following screening tests: 2, 1

• Complete blood count with differential
• Complete metabolic panel
• Erythrocyte sedimentation rate (ESR)
• C-reactive protein (CRP)
• SARS-CoV-2 PCR and/or serology

Criteria for Hospital Admission During MIS-C Evaluation

Admit for further evaluation if screening shows: 2, 4

• CRP ≥10 mg/dL (≥100 mg/L) 2, 4
• Plus at least one of: lymphopenia, neutrophilia, thrombocytopenia, hyponatremia, or hypoalbuminemia 2

Complete Diagnostic Evaluation (Tier 2) for Hospitalized Patients

For admitted patients under investigation for MIS-C, obtain: 2

• Electrocardiogram (EKG)
• Echocardiogram with detailed coronary artery evaluation
• Troponin T and BNP/NT-proBNP levels
• D-dimer, ferritin, procalcitonin, lactate dehydrogenase (LDH)
• Additional imaging as clinically indicated

Multidisciplinary Management

Children admitted with MIS-C require a multidisciplinary team including pediatric rheumatologists, cardiologists, infectious disease specialists, and hematologists 2, 1, 3

MIS-C Treatment Considerations

For confirmed MIS-C, consider: 3

• Intravenous immunoglobulin (IVIG) and/or glucocorticoids as first-tier agents
• Low-dose aspirin for patients with Kawasaki disease-like features and/or thrombocytosis
• Anticoagulation therapy for documented thrombosis or ejection fraction <35%
• Close cardiac monitoring with repeat echocardiograms at 7-14 days and 4-6 weeks after initial presentation 3

Common Pitfalls to Avoid

• Do not dismiss mild symptoms in infants, as they can decompensate rapidly, though risk factors for severe progression have not been fully identified 2
• Do not use the traditional CRP cut-off of 10 mg/L as reassuring in the MIS-C context; marked elevation is defined as ≥10 mg/dL (100 mg/L), which is 10-fold higher 4
• Do not delay evaluation if fever persists beyond typical viral illness duration, especially 2-6 weeks post-exposure 2, 1