COVID-19 Collaboration: Neonatal/Pediatric

• While some debate on its connection to COVID-19, there are reports of hyperinflammatory presentations similar to "Kawasaki Disease": overall distress but includes: fever (38-40C), rash, conjunctivitis, peripheral edema, significant GI symptoms ... all leading to shock and requiring vasopressor support (Riphagen et al, HSJ)
  Note: it is thought that this hyperinflammatory state may occur after a primary asymptomatic COVID infection.
  Note: Kawasaki Disease (mucocutaneous lymph node syndrome) is characterized by inflammation in blood vessels, often severe. Treatment includes IV immunoglobulin (AAP).  There may be chrohttps://mailchi.mp/4305add5eb41/tz4idnzryr-4783325?e=41f7747a1dnic vascular changes. 
  • See MGH FLARE on this topic 
• CDC has outlined 3 qualification in a health advisory (4/14)  
  • Under 21 with fever, lab confirmed inflammation, illness requiring hospitalization, with multi-organ failure (at least 2 systems) 
  • No alternative plausible diagnoses 
  • Some connection to COVID (+ test, antigen test, or COVID exposure in last 4 weeks) 
• Caused by a virus thought to be Droplet Transmission but also uncertainty as to whether it is Airborne.  (JAMA, WHO)
• In general, children appear less likely show mod-severe symtpms - 94% in one study (Ludvigsson, Ong et al, AAP), despite similar viral load (Jones et al)
• However, there may be evidence of age differences, with < 1 yr being at higher risk of ARDS (10%), with much lower rates in adolescents (3%) (Ong et al)
• May present as a mild flu-like illness with cough, fever, rhinnorhea (more likely to be mild symptoms) (Guo et. al, Wei et. al)
• While the majority of infants/children have mild cases, some severe cases have been noted with several deaths (CDC)
• It so far appears unlikely that a mother can pass the virus to child en utero 
• Estimates are that about 0.6 - 2.0 % of children with COVID will need PICU (CDC)
  
  
• See MGH FLARE on peri- and postartum care

While moderate-to-severe disease is reportedly less than that in the adult populations, there are case studies suggesting illness and death. This seems to correlate some to age - the older the child/teen, the more likely (though still rare) to end up critically ill.  

• Uncertainty exists about "vertical transmission" - from pregnant mother to newborn (Zeng et al, AAP)
• Testing recommended for all neonates born to women with confirmed or suspected COVID, even if asymptomatic (CDC)
• Limited, but most symptomatic newborns show signs and symptoms consistent with pneumonia, possibly sepsis, coagulopathy (Chandrasekharan et al., Zimmerman et al) 
• Some data to suggest < 12 mos is higher risk than older children (CDC)
  
  
• Procalcitonin more likely to be elevated in pediatric patients (Xia et al), or may be normal (Zimmerman et al)
• As with adults, watch for increases in ferritin (indicating inflammatory response) 
• CT Scan more likely to show consoidation with halo sign (including images: Xia et al)
• Carefully consider cardiac issues (troponins may be elevated)

Emergency Signs: (WHO)

• Obstructed or Absent Breathing 
• Severe respiratory distress 
• Central cyanosis 
• Shock, Coma, Convulsions 

Full Collaboration: See complete summaries on current PPE recommendations.  In addition: 

• Deteriorating Child (ESPINC)
  • Maintain safe distance 
  • Child should wear a mask, if possible 
• Preference for negative-pressure room (ESPINC)

• Use Airborne Precautions for Airway Management, including intubation 
• As with adults, it is advised that team members run simulations to practice steps of safe intubation and extubation 

Intubation

• Greater risk in intubating (16% develop adverse effects, 6,6% severe, 2% cardiac arrest)  (ICM)
• Minimize number of staff in the room (3 - intubator, assistant, administer drugs/monitor), ensure all appropriate PPE (ICM, AHA)
• Use strict closed-loop communication, especially with PAPR use (AHA)
• Weigh child (or estimate carefully) (ICM)
• Young children may desaturate quickly during intubation 
  • Recommendation to pre-oxygenate with 100% FIO2 for 5 minutes by nonrebreather mask, bag-valve mask, or HFNC (WHO) - some recommend not starting NIV/HFNC (ICM)
  • Due to small FRC/space, cautiously consider bag-mask ventilation using 2-handed technique and small tidal volumes (AHA)
• Person with most experience should intubate 
• Rapid Sequence Intubation is indicated (AHA, WHO)
• Intubate, confirm tube placement, then place on ventilator with inline suction (AHA)
• Preference for waveform capnography to confirm placement (difficult to ausculate with PPE) (ICM)
• Inflation of cuff should be to 20 cmH2O initially (ICM)

General Airway Care 

• Cuffed tubes should be used, microcuff as appropriate, when possible, to minimize aerosolization risk (ICM)
• Microcuff suggested size  (ICM)
  • 3.0 mm = Term > 3kg, up to < 8 mos
  • 3.5 mm = 8 mos - < 2 yrs 
  • 4.0 mm = 2 to < 4 yrs 
  • 4.5 mm = 4 to < 6 yrs 
• Standard Cuffed Size
  • Age/4 + 3.5 (ICM)
• Strong recommendation for in-line suction (ICM)
• Avoid changing out tubes, if possible (ICM)
• Clamp ET tube before any disconnection (ICM)

Oxygenation Progression of Care, may deteriorate quickly 

SpO2 Goals (WHO)

• If emergency signs (see above), perform airway management and oxygen therapy to higher target, then drop target once stable.  
• Use nasal prongs or nasal cannula in young children for tolerance. (WHO)  Ensure proper fit and position
• Intrapartum oxygenation is controversial to start with - any routine use for fetal indications should be suspended (SMFM)

As with adults, there is some disagreement around the safe use of noninvasive techniques such as HFNC, bubble CPAP, N-CPAP, CPAP, NPPV (bilevel or BiPAP) 

If at any point an FIO2 of 60% or greater is needed to keep O2 within range and/or an increased inspiratory effort (WOB) is noted, consider the need for intubation

• Due to aerosolization, use airborne precautions for all noninvasive ventilation (HFO, NIV, bubble CPAP), consider negative pressure room (WHO)
• Highflow and Noninvasive Ventilation Considerations
  • There is considerable variation between PICUs on use of HFNC vs CPAP (Kawaguchi et al)
  • Consider with hypoxemic respiratory failure (WHO)
  • Similar to viral bronchiolitis, HFNC or NIV are preferred strategies but with caution for aerosolization risk (negative-pressure room vs. open room, for example)  (AAP)
  • Consensus suggests using HFNC for the same indications as normal, but do not initiate solely to pre-oxygenate for intubation (ICM)
  • Some recommend early intubation to avoid aerosolization - this is contended (Ong et al, ICM)
• Monitor very closely for clinical deterioration 
• Note: pediatric circuits can general only handle about 25 L/min - may require an adult circuit (60 L/min) to deliver adequate flow (WHO)
  • Ensure appropraiteness (weight > 30 kg, for example) of adult circuit 
  • Consider, as with adults, maintaining flow at about 50% of normal (so max of 30 L/min) to reduce aerosolization risk 
  • If child can tolerate it, consider placing a surgical mask over interface to further diminish aerosolization 
    
    
• If using, trial for about an hour, be prepared to intubate (WHO). Remember, there should be improvement. Lack of improvement = failure. For example: 
  
  • unable to wean FIO2 adequately 
  • continued increased inspiratory effort (WOB) 
  • development of hemodynamic instability 
  • intolerance (increases risk of aerosolization with any produced leak/disconnect)
    
    
• DO NOT use NPPV as a bridge if child shows need for intubation (it is likely to fail): 
  • Apnea or inability to protect the airway (secretions, vomiting, seizure activity)
  • Hemodynamic instability (including vasopressor support) 
  • Impending respiratory arrest 
    
    
• Bubble CPAP is specifically suggested when mechanical ventilation is unavalable (WHO)

Note: as with adults, there has been some evidence that children may present with either hypoxia despite near-normal compliance (non-ARDS, hypoxic vasoconstriction) vs hypoxia with poor compliance (likely meeting criteria for ARDS).  Most consensus statements for COVID-19 recommend lung-protective strategies (ARDS)

Strategies

• Target Plateau Pressure < 28 
• Target pH 7.15-7.30 
• Avoid disconnecting from ventilator (loss of PEEP/atelectasis + aerosolization risk) 
• May need to consider continuous neuromuscular blockade in children with ARDS (WHO) when: 
  • ventilator dyssynchrony despite sedation (tidal volume limitation can't be maintained) 
  • refractory hypoxemia 
  • refractory hypercapnia 
• Clamp endotracheal tube if vent circuit needs to be disconnected (AHA)

Ventilators Equipment

• Equipment should be as closed-circuit as possible, HEPA or viral filters placed on any exhalation ports.  Dual-limb circuits are preferred over single-limb.  Some hospitals have come up with scavenger-system add-ons to minimize exposures.  

Mode 
There is no evidence to support any one mode over another

Tidal Volume

• Pediatric: target 3-6 mL/kg IBW (poor compliance) or 5-8 mL/kg (better compliance) 
• Pediatric: use target Pplat < 28, pH 7.15-7.30, VT 3-6 mL/kg with poor compliance, 5-8 mL/kg with better compliance WHO 

Rate 

• Keep rate lower/normal for higher compliance lungs
• Set rate to maintain adequate pH with more typical ARDS presentation (do not exceed 30-35 in older adolescents)

PEEP 

• Suggestion to keep PEEP levels lower (< 10) for patients with near-normal compliance (PEEP may further adversely affect pulmonary perfusion) 
• Suggestion to keep PEEP levels higher (< 15) for patients with more typical ARDS presentation 

FIO2
Prioritize use of PEEP over FIO2 when possible.  Increasing FIO2 without adequately recruiting alveoli (PEEP) will result in only minimal increases in PaO2.  High FIO2s (1.0 or 100%) may result in further atelectasis from nitrogen washout 

Critical Care 
Strategies

Proning 

Consider for pediatric patients with severe ARDS (WHO) - See the proning section in the full collaboration for much more on proning 

Recruitment Maneuver 

Consider a maneuver for refractory hypoxemia.  Modified for adult - CPAP 20 for 15-20 seconds

ECMO 

Some mixed data, but currently thought ECMO may reduce mortality (WHO)

• Avoid bronchial hygiene, including open suctioning, whenever possible 
• When absolutely necessary (such as for CF), treat as aerosol-producing. Strong recommendation for negative pressure room, all PPE (N95 or higher, goggles, gown, gloves) 

Neonatal Delivery and
Resuscitation 

Neonatal Resuscitation when Mom is COVID+ (or PUI)

Priority is on protecting the neonate

Preparation

• Any high-risk consultation should occur by phone/video if possible to minimize exposure risk  (Chandrasekharan et al.)
• High-risk delivery definitions have not changed - Maternal COVID+ does not indicate high-risk by itself (AAP)
• Increased risk of spontaneous preterm labor with critical illness (Auger et al) 
• Delivery area should be negative-pressure room if possible  (Chandrasekharan et al.)
• Mother should have mask on  (Chandrasekharan et al., AJOG)
• Delivery team with PPE (N95 or higher for person delivering neonate)
• Consider delayed cord clamping* (Chandrasekharan et al.)
• Consider no skin-to-skin contact*  - WHO recommends skin-to-skin (WHO), Others recommend placing infant on abdomen instead (Wang et al., SMH) or using caution if more serious illness (AHA)
  • Good respiratory hygeine (mask on mom) 
• Nutrition (breast-feeding) discussion* - outside realm of this page 
• If baby and mother are stable, goal should be for discharge same-day or next-day (AJOG)

Neonatal Resuscitation/Management 

• If same room, ensure at least 6-ft away from Mom + physical barrier (curtain) (Chandrasekharan et al.)
  • Can also consider resuscitation in separate room 
• Airborne precautions for any high-risk (aerosol-producing) activities: N95 or higher + goggles/shield + double gloves + gown (AHA)
• Recommendation for dedicated COVID resuscitation team  (Chandrasekharan et al.)
• Give 30-60 mins notice, when possible, to resuscitation team (to put on appropriate PPE)  (Chandrasekharan et al.)
• Most experienced resuscitator should intubate 
• Consider leaving neonate on the ventilator (HEPA filter) but time compressions with ventilation (AHA)
  • Target 4-6 mL/kg (AHA)
  • Adjust rate to 30/min (AHA)
• Resuscitation guidelines remain the same as normal except: 
  • T-piece with face mask may increase aerosolization, consider LMA
  • Suction should not be performed for uncomplicated deliveries, including for clear/meconium-stained amniotic fluid   (AHA, Chandrasekharan et al.)
• Poststabilization, neonate should be transported in a closed isolette (may reduce exposure, but doesn't protect from aerosolization), be in a negative pressure room  (AHA)

*These items should be discussed with the parent(s) prior to delivery.  Risks of exposure (to both neonate and healthcare workers) vs Benefits of performing skin-to-skin, for example, should be discussed.  

Pediatric Delivery and Resuscitation

Note that the AHA has issued Interium Guidance for Pediatric Arrest - including PALS algorithms - see AHA for full details.  These are highlights of changes recommended.  

A key aspect of care during resuscitation is to avoid exposure due to aerosolization

• Take time to put proper PPE on (N95 or above, goggles/shield, gown, gloves)
• Use bag-mask device with filter and careful, tight seal. If unavailable, use NRB mask (AHA, ESPINC)
• If delay in intubation, consider use also of a supraglottic airway (AHA)
• Priority is intubation (AHA)  preference is for a cuffed ET tube, using RSI, then place on vent (AHA, ESPINC)
• Use video larungscope 
• Person with most experience should intubate 
• Per AHA Guidelines, consider leaving on the vent during resuscitation. Vent settings: 
  • Pressure Control, A/C  with target of 6 mL/kg IBW (pediatric), 4-6 mL/kg IBW (infants)

Asthma

• Continue all inhaled drugs as ordered (GINA)
• Some reports suggest an absence of wheeze, even with patients who are prone to wheezing. Consider not using wheeze as a criteria of assessment 
• Consider MDI with spacer, if possible and appropriate 
  • for exacerbation: give every 20 mins x 3 doses. Give magnesium and IV or subcutaneous terbutaline 
• All nebulizer treatments should be considered as high-risk, aerosol-generating (AVOID, or use airborne PPE)

Cystic Fibrosis

• Minimize all face-to-face contact, as much as possible (use telehealth options)
• Note risk for rapid deterioration when COVID+, keep this strongly in mind with all clinical plans (NICE)
• Avoid any "routine" visits to the healthcare facility (clinics, PFTs, etc.) 
• All home treatments should continue 
• If hospitalized, consider appropriateness of negative-pressure rooms.  
• Do not withhold bronchial hygiene, but use self-directed when possible (vest-like treatments, for example).  Clinician should step away from patient as much as possible during active treatment. 
• Do not withhold drugs, but consider with team the appropriateness of MDI - if nebulizer needed, as is likely, be sure to treat as high-risk (aerosol-producing)