Clinical Management of Children Summary

Data from the Centers for Disease Control and Prevention demonstrate a lower incidence of SARS-CoV-2 infection, severe disease, and death in children compared with adults.^1-4 Although only a small percentage of children with COVID-19 will require medical attention, the percentage of intensive care unit admissions among hospitalized children is comparable to the percentage among hospitalized adults with COVID-19.^5-16

Risk factors for severe COVID-19 have been identified through observational studies and meta-analyses primarily conducted before the availability of COVID-19 vaccines. Risk factors include having ≥1 severe comorbid conditions, such as medical complexity with respiratory technology dependence, a neurologic condition resulting in impaired mucociliary clearance, obesity (particularly severe obesity), severe underlying cardiac or pulmonary disease, or severely immunocompromised status. However, pediatric data on risk factors for severe COVID-19 are generally more limited and provide lower certainty than data for adults.

In general, COVID-19 has similar clinical manifestations and disease stages in children and adults, including an early phase driven by viral replication and a late phase that appears to be driven by a dysregulated immune/inflammatory response to SARS-CoV-2 that leads to tissue damage. Respiratory complications in young children that can occur during the early clinical phase include croup and bronchiolitis. In addition, a small number of children who have recovered from acute SARS-CoV-2 infection develop multisystem inflammatory syndrome in children (MIS-C) 2 to 6 weeks after infection. MIS-C is a postinfectious inflammatory condition that can lead to severe organ dysfunction, which is in contrast to COVID-19, the acute, primarily respiratory illness due to infection with SARS-CoV-2.

There are no results available from clinical trials that evaluated treatments for COVID-19 in children, and data from observational studies are limited. Applying adult data from COVID-19 trials to children is a unique challenge because most children experience a mild course of illness with COVID-19. Relative to adults, children with COVID-19 have substantially lower mortality and less need for hospitalization. Because of these differences in epidemiology and disease severity, the effect sizes for children are likely to be smaller than those observed in adults; therefore, to produce a beneficial outcome, the number needed to treat is higher. Collectively, these factors influence the risk versus benefit balance for pharmacologic therapies in children.

In the absence of sufficient clinical trial data on the treatment of children with COVID-19, the COVID-19 Treatment Guidelines Panel’s (the Panel) recommendations for the therapeutic management of children are based largely on adult safety and efficacy data from clinical trials, the child’s risk of disease progression, and expert opinion. In general, the older the child and the more severe the disease, the more reasonable it is to follow treatment recommendations for adult patients with COVID-19.

The Panel’s recommendations for the management of children with COVID-19 or MIS-C are summarized in the tables below. Table 3a provides recommendations for the therapeutic management of nonhospitalized children with COVID-19. The Panel’s recommendations are stratified by age (per the Food and Drug Administration Emergency Use Authorizations) and risk level. See Therapeutic Management of Nonhospitalized Children With COVID-19 for more information. Table 3b includes a framework to help clinicians evaluate the risk for severe COVID-19 based on patient conditions and COVID-19 vaccination status.

The recommendations for hospitalized children in Table 3c are stratified by disease severity. See Therapeutic Management of Hospitalized Children With COVID-19 for more information. Table 3d summarizes the recommendations for the therapeutic management of MIS-C. For the rationale behind these recommendations and supporting data, see Therapeutic Management of Hospitalized Pediatric Patients With Multisystem Inflammatory Syndrome in Children (MIS-C) (With Discussion on Multisystem Inflammatory Syndrome in Adults [MIS-A]).