AMMI Canada Practice Point on the treatment of acute COVID-19 in pediatrics

 In patients with positive SARS-CoV-2 testing and acute respiratory, cardiac or neurological symptoms of concern:o The Critical Care Response Team (CCRT) should be made aware of patients upon admission and subsequently if there is evidence of clinical deterioration that might necessitate ICU care. In patients with positive SARS-CoV-2 testing where clinical symptoms might be reasonably explained by a clear alternate diagnosis: o Infectious diseases service consultation is at the discretion of the primary care team Patients requiring critical care support: Critical Care team, Respiratory Medicine, ID, thrombosis team and Infection Control services should be engaged.An initial multidisciplinary team meeting it is strongly recommended involving services likely be engaged if the patient further deteriorates: including Rheumatology, Immunology, Haematology/Oncology, and Clinical Pharmacology.Risk factors for severe illness in children with COVID-19  Risk factors for severe COVID-19 in children are not yet clearly defined. Populations that may be at higher risk for severe infection include infants <1 year of age, and children with comorbid conditions including: lung disease, immune compromise, obesity, congenital heart disease, sickle cell disease, genetic abnormalities, neurological disease, or diabetes mellitus. Acute respiratory distress syndrome (ARDS) and children with COVID-19In general, the principles of management of paediatric ARDS secondary to COVID-19 are likely to be aligned with those of the adult population.Specific management of ARDS in children with COVID-19 should be assessed on a case-by-case basis under the direction of critical care and respiratory teams. Management considerations for CRS/secondary HLH and related inflammatory clinical entities secondary to COVID-19 The routine use of immunomodulatory agents other than corticosteroids in children with COVID-19 outside of clinical trials is not recommended  On a case-by-case basis where there is evidence of worsening disease such as, increasing oxygen or ventilator requirement and/or evidence of systemic inflammation (e.g.elevated CRP), immunomodulatory agents such as tocilizumab and anakinra may be considered under expert guidance from specialist teams as detailed above. In particular, for older children, aged 12 to 18 years, who have confirmed COVID-19 with moderate to severe disease managed in a ward level setting and have risk factors for disease progression, such as elevated BMI, tocilizumab* may be considered on a case-by-case basis in patients who have evidence of systemic inflammation (CRP 75 mg/L or higher) AND evidence of disease progression (increasing oxygen or ventilatory requirements) despite 24-48 hours of optimal dexamethasone therapy. For older children, aged 12 to 18 years, who have confirmed COVID-19 with severe or critical disease requiring intensive care setting management and are receiving optimal dexamethasone therapy, tocilizumab* may be considered on a case-by-case basis *Evidence for tocilizumab use based on treatment given within 14 days of hospital admission SickKids COVID-19 Case Management Interim Guidance.

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