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Table 3d. Therapeutic Management of Hospitalized Pediatric Patients With MIS-C

Last Updated: December 28, 2022

Table 3d. Therapeutic Management of Hospitalized Pediatric Patients With MIS-C
Patient ConditionPanel’s Recommendations
MIS-CInitial treatment for MIS-C includes both immunomodulatory and antithrombotic therapy.
Initial Immunomodulatory Therapy
  • IVIG 2 g/kg IBW/dose (up to a maximum total dose of 100 g)a IV plus low-to-moderate dose methylprednisolone (1–2 mg/kg/day) IVa or another glucocorticoid at an equivalent dosea (AIIb).
  • The Panel recommends against the routine use of IVIG monotherapy for the treatment of MIS-C unless glucocorticoid use is contraindicated (AIIb).
Intensification Immunomodulatory Therapy
  • For children with refractory MIS-C who do not improve within 24 hours of initial immunomodulatory therapy, start 1 of the following (listed in alphabetical order) (AIII):
    • High-dose anakinra 5–10 mg/kg IV or SUBQ daily (BIIb), or
    • Higher-dose glucocorticoid (e.g., methylprednisolone 10–30 mg/kg/day IV or equivalent glucocorticoid) (BIIb),b or
    • Infliximabc 5–10 mg/kg IV for 1 dose (BIIb).
Antithrombotic Treatment
  • Low-dose aspirin (3–5 mg/kg/day, up to maximum daily dose of 81 mg) PO for all patients without risk factors for bleeding (AIII), AND
  • Anticoagulation for patients who fall under 1 of the following clinical scenarios:
    • Therapeutic anticoagulation for patients with large CAAs according to the American Heart Association guidelines for Kawasaki disease (AIII).
    • Therapeutic anticoagulation for patients with moderate to severe LV dysfunction who have no risk factors for bleeding (AIII).
    • For patients with MIS-C who do not have large CAAs or moderate to severe LV dysfunction, consider prophylactic or therapeutic anticoagulation on an individual basis, taking into consideration risk factors for thrombosis. See Table 3e for additional information.
Each recommendation in the Guidelines receives 2 ratings that reflect the strength of the recommendation and the quality of the evidence that supports it. See Guidelines Development for more information.

a Duration of therapy may vary. For more information, 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]).

b In certain patients with severe illness, intensification therapy may include dual therapy with higher-dose glucocorticoids and infliximab or anakinra. Anakinra and infliximab should not be given in combination..

c Infliximab should not be used in patients with macrophage activation syndrome.

Key: CAA = coronary artery aneurysm; IBW = ideal body weight; IV = intravenous; IVIG = intravenous immunoglobulin; LV = left ventricular; MIS-C = multisystem inflammatory syndrome in children; PO = oral; SUBQ = subcutaneously