MANAGEMENT OF COVID-19 AT COMMUNITY LEVEL, NON-ICU SETTINGS, CRITICAL CARE MANAGEMENT AND NEONATAL COVID.

1. MANAGEMENT
OF COVID-19
PRESENTER: DR.PRADEEP
MODERATOR: DR.HARISH SIR

2. MANAGEMENT OF
COVID-19 IN
COMMUNITY AND NON-
ICU SETTINGS

3. COMMUNITY MANAGEMENT:
All children suspected of having COVID-19 exposure or infection with mild symptoms should be
advised quarantine in COVID-19 isolation centres , if available or they may be advised home
quarantine
Home quarantine :
Patients should preferably stay in well ventilated single rooms with attached bathrooms.
If another person other than care taker of a small child needs to share the room, he should
maintain a distance of one metre at all times.
 He/she should stay away from older adults, pregnant ladies, other children and patients with
comorbidities.

4. They should practice strict personal hygiene, including hand hygiene and wearing of masks.
Masks used by patients /close contacts during home care should be disinfected using ordinary bleach
solution (5%) or sodium hypochlorite solution (1%) and then disposed of either by burning or deep
burial.
Family members cleaning the room or handling soiled linen should wear disposable gloves and wash
hands with soap and water after removing gloves.
Patients should seek medical advice if any COVID-19 infection symptoms appear including fever,
cough, diarrhoea, vomiting or breathlessness and all close contacts in such a situation should be home
quarantined (for 14 days).

5. HOSPITAL MANAGEMENT:
 In the COVID-19 isolation areas, the patient should be triaged for the severity of the
infection
Triage questions :
1. Has someone in your close family returned from a foreign country? Yes/No
2. Is the patient under home quarantine as advised by the local health authority?
Yes/No
3. Have you or someone in your family come in close contact with a confirmed COVID-
19 patient in the last 14 days? Yes/No
4. Do you have fever? Yes/No
5. Do you have cough /sore throat? Yes/No
6. Do you feel shortness of breath? Yes/No

6. CLINICAL CATEGORISATION
FOR PLANNING THERAPY:
All children with suspected COVID-19 infection should be categorized into three categories.
Category A (Mild symptomatic patients) :Mild sore throat, fever, cough, rhinorrhea,
vomiting.
Category B (moderate symptoms / patient with comorbidities) : Fever, severe sore
increasing cough. Category A symptoms in children with chronic heart, kidney, lung,
neurological or liver disease and children on long term steroids, congenital or acquired
immunosuppression.
Category C (severe and critical disease) : Altered sensorium, respiratory distress, SpO2 <
breathlessness, cyanosis, inability to feed, seizures, hypotension.

7. SEVERITY CATEGORY A CATEGORY B
CLINICAL CRITERIA ▪ Fever
▪ Sore throat
▪ Rhinorrhea
▪ Cough
▪ Diarrhoea ▪ Vomiting ▪ Pain abdomen
❑ Fast breathing (age-based criteria)
▪ <2 months: ≥60/min
▪ 2-12 months: ≥50/min
▪ 1-5 years: ≥40/min
▪ >5 years: ≥30/min
❑ SpO2 90-94%
WHAT TO DO? HOME ISOLATION ADMIT IN COVID-WARD
INVESTIGATIONS ▪ None ▪ If there is high grade fever for >3-4 days
– investigate for – CBC, CRP, Urine R/E, Blood C&S,
C&S, CXR
▪ At admission: CBC,SE,LFT,RFT, CRP, PT,INR,APTT,
D-dimer, blood culture, CXR (Dengue/MP/Weil
Felix etc clinically directed)
WHEN TO REPEAT Clinically directed ▪ Repeat after 48-72 hours, as per clinical course
TREATMENT. ▪ Paracetamol 10-15 mg/kg
▪ Ensure adequate hydration
▪ Physical distancing, Mask, Strict hand hygiene
▪ ORS, Zinc, if child has diarrhoea
▪ Reassurance and counsel about danger signs
▪ No Antibiotics for 3 days of high fever, start
Amox/Amoxclav /Azithromycin if bacterial inf
suspected
▪ Paracetamol 10-15 mg/kg, 4-6 hourly for fever
▪ Oral feeding or IV fluids
▪ Correct dehydration, if present
▪ Oxygen (nasal prongs / NRM) if SpO2 <94%
or increasing distress
▪ Awake proning (if possible, 2 hourly position
change)
▪ Antibiotic (Amox-clav +/- Azithromycin )
▪ Steroids.

8. WHAT TO MONITOR?
EVERY 2-4 hourly.
▪ HR,BP,CFT
▪ RR,SpO2
▪ Temperature
▪ Oral intake ,U/O and hydration status
▪ Sensorium

9. RED FLAG SIGNS:
 Persistent fever (>102 F) ≥4-5 days
Rapid breathing, cyanosis or SpO2 <94%
Poor oral intake, pain abdomen, loose stools
Lethargy/irritability, rash
Decreased U/O, dry mucosa, sunken eyes

10. INFECTION PREVENTION &
CONTROL IN COVID-19 SCENARIO
Infection prevention and control (IPC) measures are of paramount importance in
managing patients with COVID-19 infection.
 Encourage all patients to wear masks, and advice patients to keep 1-metre distance
between them.
 Use PPE while entering the room with a triple layer mask, gown and goggles and
remove when leaving.
 Aerosol precautions should be taken while doing aerosol-generating procedures.
 Disinfection of equipment, cleaning of patient’s surrounding and safe disposal of
waste are also part of IPC measures.
Hand hygiene.

11. CRITICAL CARE
MANAGEMENT OF
COVID-19

12. INDICATIONS OF PICU
ADMISSION:
 Requirement for significant respiratory support that cannot be provided
elsewhere such as non-invasive or invasive ventilation. This may be due to
hypoxia, hypercarbia or increased work of breathing.
 Requirement for cardiovascular support including multiple fluid boluses or
inotropes. This may be because of hyperinflammatory syndrome,
myocarditis or significant co-infections.
 Deterioration of neurological status. This may be due to direct COVID-19
related neurological complications (e.g. seizures, encephalopathy) or
related to respiratory complications such as hypoxia.
 Any child considered to be at risk of further deterioration requiring
continuous or close monitoring requiring higher nurse: patient ratios.

13. HFNC OXYGEN THERAPY:
 Children with hypoxia (oxygen saturation <92%) should receive supplemental
oxygen.
 In the children who require higher concentration of supplemental oxygen,
heated and humidified oxygen with HFNC may be well tolerated and may
reduce the need for invasive ventilation.
 It is probably safe to use HFNC for children with mild-moderate disease severity,
especially if the HCW uses full PPE and children are nursed in cubicles.
 Routine monitoring of heart rate, respiratory rate, fractional inspired oxygen
(FiO2 ), work of breathing and comfort levels are essential to assess the
effectiveness of HFNC therapy.

14. NON-INVASIVE VENTILLATION:
 NIV using a full face or oro nasal mask interface can be tried in selected
patients based on local experience.
 Bubble CPAP may especially be a useful mode of support in young infants.
 Intubation must be recommended if there is no improvement in oxygenation
(target SpO2 92 - 97% and FiO2 < 0.6) within 60-90 minutes of initiating NIV

15. INVASIVE VENTILATION:
Strategies to minimise HCW protection from aerosols during invasive mechanical ventilation
of suspected or confirmed COVID-19, may include:
The use of appropriate full PPE
Inline suction
Minimise circuit disconnection
Temporary clamping of endotracheal tube (ETT) when disconnection is essential
Passive humidification with a heat moisture exchanger (HME) filter rather than active
humidification, viral filter in the expiratory limb of the ventilator circuit
Pre-attached viral filters in bagging circuits for use in emergencies.

16. Initial setting should aim to achieve:
 Tidal volumes between 4 to 8 mL/kg of ideal body weight,
 PEEP between 6 to 10 cm H2 O and
 Plateau pressure under 28 cm H2 O.
 Permissive hypoxia (SpO2 88-92% if PEEP >10, or else 92-97% if PEEP <10cm
H2O )and permissive hypercapnia(if pH<7.15) are acceptable to achieve
optimal lung protection.
 Prone ventilation can improve oxygenation and lung homogeneity in children.
children.
 It is likely that pediatric critical care units have had already experience with
proning and have set policies and procedure which would help them to adapt
adapt to it.

17. OTHER SUPPORTIVE CARE:
Judicious fluid management is the key to the care of any critically ill child.
Following restoration of intravascular volume a restriction of daily allowance
70-80% of calculated fluid requirement using Holliday-Segar formula is a good
starting point.
Enteral feeding should be commenced at the earliest possible opportunity, if
to do so.
Empirical antibiotics are justified until a diagnosis is established and/or co-
infections are excluded even if the SARS-CoV-2 PCR is positive.

19. CASE DEFINITION OF MIS-C:
 Younger than 21 years, with fever >3days AND,
 Elevated markers of inflammation (ESR, CRP, PROCALCITONIN) AND,
 No other cause of microbial inflammation (bacterial sepsis) AND,
 Evidence of COVID-19 (RT-PCR, antigen test) or likely contact with patients with COVID-19
AND,
AND ANY 2 OF THESE:
 Rash or bilateral non-purulent conjunctivitis or muco-cutaneous inflammation signs (oral,
hands, feet).
 Hypotension or shock,
 Evidence of coagulopathy,
 Acute GI problems (diarrhoea, vomiting, pain abdomen),
 Features of myocardial dysfunction or coronary abnormalities (elevated Troponin).

24. NEONATAL COVID-19

25. INTRODUCTION:
 The general information from the literature so far indicates that
neonatal COVID-19 infection may be uncommon.
 It is generally acquired through postnatal transmission rather than
vertical transmission.
 Newborn infants with COVID-19 infection exhibit either no
symptoms or mild respiratory illness.
 The higher percentage of fetal hemoglobin in newborn infants may
be protective over SARS-CoV-2

26. DEFINITION:
SARS-CoV-2 infected neonates were defined as those with a positive SARS-CoV-2
quantitative RT-PCR test in nasopharyngeal swab within 28 days of birth.
The perinatal transmission was defined as positive nasopharyngeal RT-PCR in a
neonate in the first 72 hours after birth. This included intrauterine and intrapartum
transmission. Testing was avoided in the first 12 hours to minimize false positives due to
superficial colonization.
The horizontal transmission was considered in a neonate with negative RT-PCR within
the first 72 hours who subsequently tested positive any time after 72 hours of birth
irrespective of the mother's SARS-CoV-2 status.

27. MATERNAL TRANSMISSION TO
NEWBORN:
3 Potential mechanisms of maternal transfer of SARC COV-2 to the infant:
1. INTRAUTERINE TRANSMISSION through transplancental hematogenous spread or viral particles in
amniotic fluid that are ingested or inhaled by the fetus. This mode appears less likely but there are
are reports suggesting that this is possible.
2. INTRAPARTUM TRANSMISSION after exposure to maternal infected secretions or feces around the
time of birth.
3. POSTPARTUM TRANSMISSION from an infected mother, family member, or health care worker
(probably the most likely mode of transmission). Transmission from infected mother is more likely
from respiratory secretions and less likely from breast milk.

30. DIAGNOSIS:
Diagnosis of a newborn infant born to a suspected or COVID positive mother is imperative.
RT-PCR testing of nose and throat swab for detection of SARS-CoV-2 nucleic acid has been recommended
as the confirmatory test for COVID19.
Other alternative sample could be endotracheal aspirate.
Whom to test: All newborn infants who have any one of the following:
1) History of exposure to COVID-19 positive adult (irrespective of symptoms), mother had COVID-19
infection within 14 days before birth, history of contact with COVID-19 positive persons (including mother,
family members in the same household or direct healthcare provider) in the postnatal period.
2) Irrespective of history of exposure: Presenting with pneumonia or severe acute respiratory infection
(SARI) that require hospitalization, with onset at more than 48-72 hours of age, unless there is another
underlying illness that completely explains the respiratory signs and symptoms

31. When to do the test
a) At birth (if mother had COVID-19) or at detection of the history of contact with COVID-
19 positive person (postnatal exposure)
b) If a sample is not obtained at birth due to logistic reasons, it should be obtained as soon
soon as possible.
When to do repeat test?
If the first test is negative, a repeat test should be done after 5-14 days of birth/exposure.
However, the test should be done immediately, if new symptoms such as respiratory
distress, lethargy, seizures, apnea, refusal to feed, diarrhoea appear.

32. ANTENATAL MANAGEMENT:
Pregnant women should follow the same recommendations as nonpregnant adults for avoiding
exposure to the virus like social distancing, hand hygiene, disinfecting surfaces and wearing a mask in
public.
 Pregnant women with confirmed COVID-19 should be managed with supportive care recommended for
non-pregnant adults. Currently recommended management includes: oxygen therapy/respiratory
support for treatment of hypoxemic respiratory failure, fluid therapy, antibiotics and management of
shock.1
All COVID-19 positive pregnant women should be referred to designated COVID care facility.
Antenatal steroids have proven benefits in neonatal mortality and morbidity, in pregnant women
between 24+0 and 33+6 weeks of gestation with suspected or confirmed COVID-19.16 For pregnant
women between 34+0 and 36+6 weeks of gestation, these decisions may need to be individualized

33. DELIVERY ROOM MANAGEMENT:
The mode of delivery and anesthesia is best decided as per maternal and fetal indications.
The optimal location for neonatal stabilization and resuscitation could be in an adjacent room or the
same place at least 6 feet or 2 meters away from the mother with a physical barrier.
Neonatal resuscitation should be performed according to the Neonatal Resuscitation India.
Following key aspects must be kept in mind during resuscitation
During initial steps: Routine neonatal care and the initial steps of neonatal resuscitation are unlikely to
be aerosol generating, however, suction of the airways is an aerosol generating procedure and should
not be performed routinely for clear or meconium-stained amniotic fluid.
Transport to NICU: Closed incubator transfer should be used to transfer newborns

34. SHOULD WE CONTINUE DELAYED CORD
CLAMP & SKIN TO SKIN CONTACT
PRACTICED ?
Delayed cord clamping and skin-to-skin contact can be practiced. WHO
recommends skin to skin care and rooming-in.
There are problems with separation approach, as separation limits
opportunities for parent teaching, disrupts breastfeeding and may have negative
impacts on mother-newborn bonding.
Rooming-in during hospitalization helps mother and family to learn infection
prevention practices.

35. CAN THE INFANT BREASTFED ?
The possibility of the vertical transmission of SARS- CoV-2 through breast milk
could not be confirmed.
The Indian team (FOGSI, NNF and IAP) recommends rooming in and
breastfeeding with strict precautionary measures.
If an infected mother chooses not to nurse her newborn, she may express
breastmilk after appropriate hand hygiene, and fed by unaffected caregivers.
Finally, with the available current evidence, benefits of breastfeeding outweigh
the risks of passing infection from mother to infant.

36. WHEN THE INFANT IS READY
FOR HOSPITAL DISCHARGE?
1. IF INFANTS SARS COV-2 TESTING IS POSITIVE, but the infant has no signs of COVID-19.plan for frequent outpatient
follow up for 14 days after birth. During this period take percuations to prevent spread from infant to caregivers.
2. IN MOST CASES THE INFANTS SARS COVID-2 TESTING WILL BE NEGATIVE where infant should be discharged and
measures to be taken by mother by wearing mask and hand hygiene when directly caring for the infant until:
She has been afebrile for 24 hrs without use of antipyretics.
At least 14 days have passed since her symptoms first appeared.
Symptoms have improved.
3. IF THE INFANT CANNOT BE TESTED, then treat the infant as virus positive for 14 day period of observation.

38. RECENT STUDY:
Outcomes of Neonates Born to Mothers with Coronavirus Disease 2019
(COVID-19) – National Neonatology Forum (NNF) India COVID-19 Registry.
By Postgraduate Institute of Medical Education and Research (PGIMER),
Chandigarh, India.
Published @ March 20,2021.
In this prospective cohort study, Limited evidence exists on perinatal
transmission and outcomes of severe acute respiratory syndrome coronavirus-2
(SARS-CoV-2) infection in neonates.

39. STUDY INCLUDES:
Neonates born to women with SARS-CoV-2 infection within two weeks prior to or two days after
delivery and neonates with confirmed SARS-CoV-2 infection within 28 days of life were eligible for
enrolment in the study.
All neonates were monitored for clinical symptoms for the first seven days after birth and for as long
as the mother was admitted to the hospital.

40. RESULT:
Total cases received by COVID-19 REGISTRY= 1733 cases.
1649 (95%) government hosp.
82 (5%) private hosp.
Out of 1733 cases 22 cases were excluded as both mother and neonate were negative
for COVID-19.
Remaining 1711 ( 95% were asymptomatic,
4% symptomatic,
1% were critically ill.)

41. Total intramural cases -1589.
Out of which test not done in – 259.
Remaining neonates tested -1330.
Total positive cases – 189.
Positive within 72 hours (perinatal transmission) – 168.
Positive >72 hours (horizontal transmission) -21.

42. The risk of transmission was not associated with the mode of delivery or type of
feeding. The risk of transmission of SARS-CoV-2 from mother to neonate was
marginally higher if the baby was roomed-in with the mother.
The prematurity rate, which was higher in SARS-CoV-2 positive group. SARS-CoV-2
positive neonates were five times more likely to be symptomatic and twice more
likely to need resuscitation. They had significantly higher probability of having
sepsis and septic shock. SARS-CoV-2 positive neonates were more likely to have
abnormal radiological findings and need respiratory support. They were also more
likely to have received surfactant, steroids, and inotropes.

43. DISCUSSION:
This study highlights that SARS-CoV-2 positive neonates are more likely to be
symptomatic, more likely to have respiratory symptoms, and other neonatal
morbidities. However, the mortality is not increased significantly.
Common symptoms reported include respiratory distress, fever, and those related to
gastrointestinal illness. Most of the infected neonates were not reported to need any
respiratory support and had a good outcome after a median duration of hospitalization
of 10 days.
 Another important finding in our cohort is that SARS-CoV-2 infected neonates were
significantly more likely to need resuscitation, be symptomatic, need NICU admission,
have abnormal chest X-rays, and need respiratory support.

44. THANK YOU ....