The DGHS recommended steroids only in hospitalised moderately severe and critically ill COVID-19 cases under strict supervision
The guidelines suggested rational use of High-resolution CT (HRCT) for seeing the extent and nature of lung involvement in patients with COVID-19
The Indian government has come out with comprehensive guidelines for the management of COVID-19 among children below 18 years of age in which Remdesivir has not been recommended and rational use of HRCT imaging (CT Scan) has been suggested.
The guidelines issued by the Directorate General of Health Services (DGHS) under the health ministry also said that steroids are harmful in asymptomatic and mild cases of infection.
• Steroids are not indicated and are harmful in asymptomatic and mild cases of COVID-19
• Indicated only in hospitalized moderately severe and critically ill COVID-19 cases under strict supervision
• Steroids should be used at the right time, in right dose and for the right duration
• Self-medication of steroids must be avoided
• Indications and recommended dose: Corticosteroids may be used in rapidly progressive moderate and severe cases. The recommended dose is as below:
Dexamethasone 0.15 mg/kg per dose(maximum 6 mg) twice a day or equivalent dose of methylprednisolone may be used if dexamethasone is unavailable, for 5–14 days depending on clinical assessment on daily basis
• It must be remembered that steroids prolong viral shedding and hence caution is required in their use.
Recommended dose in severe COVID-19 and MIS-C
o Aspirin: 3 mg/ kg/day to 5 mg/kg/day max 81 mg/ day (if thrombosis or Coronary aneurysm score ≥ 2.5)
o Low molecular weight heparin (Enoxaparin): 1mg/kg twice daily subcutaneously
o Clotting factor Xa should be between 0.5–1 IU/ml (if patient has thrombosis or coronary aneurysm score >10 or LVEF <30%)
The guidelines suggested rational use of High-resolution CT (HRCT) for seeing the extent and nature of lung involvement in patients with COVID-19.
"However, any additional information gained from HRCT scan of the chest often has little impact on treatment decisions, which are based almost entirely on clinical severity and physiological impairment.
"Therefore, treating physicians should be highly selective in ordering HRCT imaging of the chest in COVID-19 patients," the guidelines said.
They said COVID-19 is a viral infection, and antimicrobials have no role in the prevention or treatment of uncomplicated COVID-19 infection
For asymptomatic and mild cases, the guidelines said antimicrobials are not recommended for therapy or prophylaxis while for moderate and severe cases antimicrobials should not be prescribed unless there is clinical suspicion of a superadded infection.
Hospital admission increases the risk of healthcare-associated infections with multidrug-resistant organisms.
For asymptomatic infection among children, the guidelines recommended no specific medication and promoted COVID-appropriate behaviour (mask, strict hand hygiene, physical distancing) and suggested giving nutritious diet.
The guidelines said that for mild infection paracetamol 10-15mg/kg/dose may be given every 4-6 hours for fever and throat soothing agents and warm saline gargles in older children and adolescents have been recommended for cough.
In case of moderate infection, the guidelines suggested initiating immediate oxygen therapy.
"Corticosteroids are not required in all children with moderate illness; they may be administered in rapidly progressive disease and anticoagulants may also be indicated," the guidelines said.
For severe COVID-19 among children, the guidelines said if Acute Respiratory Distress Syndrome (ARDS) develops, necessary management to be initiated.
"In case shock develops, necessary management should be initiated. Antimicrobials to be administered if there is evidence/strong suspicion of superadded bacterial infection. May need organ support in case of organ dysfunction, e.g. renal replacement therapy," it said.
Six-minute walk tests:
The guidelines also recommended a six-minute walk test for children above 12 years under the supervision of parents/guardians. These are:
To be used in children above 12 years under supervision of parents/guardian
• It is a simple clinical test to assess cardio-pulmonary exercise tolerance, and is used to unmask hypoxia
• Attach pulse oximeter to his/her finger and ask the child to walk in the confines of their room for 6 minutes continuously
• Positive test: any drop in saturation < 94%, or absolute drop of more than 3–5% or feeling unwell (lightheaded, short of breath) while performing the test or at end of 6 minutes
• Children with positive 6-minute walk test may progress to become hypoxic and early admission to hospital is recommended (for observation and oxygen supplementation)
• The test can be repeated every 6 to 8 hours of monitoring in home setting; avoid the test in patients with uncontrolled asthma
Earlier, AIIMS Delhi Director Dr Randeep Guleria on Tuesday said there is no data, either from India or internationally, to show that children will be seriously infected in any next wave of COVID-19.
Addressing a joint press conference on the COVID-19 situation here, Dr Guleria said it is a piece of misinformation that subsequent waves of the COVID-19 pandemic are going to cause severe illness in children.
"There is no data - either from India or globally - to show that children will be seriously infected in subsequent waves," he said.
He said 60 - 70 per cent of the children, who got infected and got admitted in hospitals during the second wave in India, had either co-morbidities or low immunity and healthy children recovered with mild illness without need for hospitalization.
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