Coronavirus Disease 2019 (COVID-19)

Patient Population: Pediatric

The following guidelines are based on evidence assessment and published guidance at the time of review, and are subject to further changes as new COVID-19 treatment evidence emerges and new guidance is published.  

This section focuses on specific antiviral, immunomodulatory and monoclonal antibody therapies for COVID-19. See comprehensive pediatric COVID-19 and MIS-C management guidelines that incorporate recommendations below. 

Guidance for outpatient therapies for COVID-19 including monoclonal antibody and oral antiviral can be found here

The recommendations below were updated 1/21/22. 

Condition Major Pathogens  First Choice Therapy Alternative Therapy Comments
Pre-exposure prophylaxis in certain hiigh risk patients unable to develop antibody response to immunization SARS-CoV-2 Pre-exposure prophylaxis may be used in patients meeting criteria - see separate resource linked in above full guideline    
High risk patient with exposure to coronavirus disease 2019 (COVID-19) Same

No specific therapy

  Monitor for development of symptoms
Coronavirus disease 2019 (COVID-19), asymptomatic Same No specific therapy    Monitor for development of symptoms

Coronavirus disease 2019 (COVID-19), mild-moderate  

Mild: No new or increased supplemental oxygen requirement, with symptoms limited to upper respiratory tract 

Moderate: No new or increased supplemental oxygen requirement, with symptoms involving the lower respiratory tract, or radiographic findings on chest X-ray 

Same 

Supportive care is recommended for most patients

Inpatient antiviral therapy may be considered on a case-by-case basis as outlined in pediatric multicenter guidance 

Outpatient therapy may be considered for high risk patients if indicated per Emergency Use Authorization and local criteria and based on availability - refer to guidelines linked above for details. 

See severe-critical section below if treating with antiviral therapy 

   

Coronavirus disease 2019 (COVID-19), severe-critical 

Severe: new or increased requirement for supplemental oxygen 

Critical: new or increased requirement for invasive or noninvasive mechanical ventilation, sepsis, multiorgan failure, or rapidly worsening clinical trajectory that does not yet meet these criteria 

Same

Remdesivir:

Age <12 years and/or weight < 40 kg: 
Remdesivir  lyophilized powder only 

Weight 3.5-40 kg:
5 mg/kg/dose IV on day 1, then 2.5 mg/kg/dose IV q24h 

Age ≥12 years and weight >40 kg: 
Remdesivir injection solution or lyophilized powder 

Weight >40 kg:
200 mg/dose IV on day 1, then 100 mg/dose IV q24h 

See 4th column for emergency use authorization treatment details and monitoring, last column for duration 

AND 

Dexamethasone*
0.15 mg/kg/dose (max 6mg/dose) IV or enterally q24h (see last column for duration)  

For patients especially adolescents with substantially escalating respiratory support needs (requiring critical care) after initiation of remdesivir and dexamethasone, consider adding baricitinib OR tocilizumab in consultation with ID. There is not yet sufficient data to recommend routinely adding these medications in pediatric patients. 

Refer to baricitinib Emergency Use Authorization (applies to age >= 2 years) for treatment and monitoring details and discuss with ID

Refer to tocilizumab Emergency Use Authorization (applies to age >=2 years) for treatment and monitoring details and discuss with ID

Remdesivir is FDA approved for treatment of hospitalized patients >= 12 years and >= 40kg 
 
Treatment for hospitalized patients not meeting above criteria remains available via Emergency Use Authorization which includes specific requirements: 

Provide fact sheet to patient’s caregiver. English and Spanish versions available here. Obtain informed assent from caregiver including discussion that medication is not yet FDA approved for patients < 12 yo or <40 kg 

Use the age-appropriate remdesivir order panel to ensure adherence to criteria.  

Monitoring for remdesivir:  
 
Monitor hepatic panel at baseline and during therapy 

ALT >10 times the upper limit of normal and asymptomatic: Consider discontinuing remdesivir. 

ALT elevation AND signs or symptoms of liver inflammation: Discontinue remdesivir. 

Although the manufacturer's labeling recommends against use in patients with eGFR <30 mL/minute, significant toxicity with a short duration of therapy (e.g., 5 to 10 days) is unlikely.  

ID approval is required for  baricitinib use but not remdesivir use

Duration:  

Remdesivir: 
Severe disease: 5 days 

Critical disease: 5-10 days, guided by clinical course 

Dexamethasone:  
Up to 10 days or until hospital discharge, whichever comes first   

*Consider risks vs. benefits of dexamethasone in relationship to underlying conditions (e.g. prior immunosuppression, metabolic disease, etc.) especially in patients with less severe respiratory illness e.g. not requiring mechanical ventilation.  

Multisystem inflammatory syndrome in children (MIS-C) 

  

Post-infectious phenomenon following SARS-CoV-2 infection  Antiviral treatment is not routinely indicated, unless acute COVID-19 is also a diagnostic consideration, and patient would meet above criteria for severe or critical disease.  
 
Other management of MIS-C is currently outside the scope of this section. Refer to comprehensive COVID-19 and MIS-C guidelines linked above.
 

Rheumatology consult recommended 

Consider ID consult if needed to distinguish other etiologies if MIS-C diagnosis is not clearly established

References: 

Chiotos K, et al. Multicenter interim guidance on use of antivirals for children with coronavirus disease 2019/severe acute respiratory system coronavirus 2. J Pediatr Infect Dis Soc 2021;10:34-48.

Wolf J, et al. Initial guidance on use of monoclonal antibody therapy for treatment of COVID-19 in children and adolescents. J Pediatr Infect Dis Soc 2021;10:629-634.

COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. 

Bhimraj A, et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19 

American Society of Health-System Pharmacists. Assessment of evidence for COVID-19-related treatments. Available at: ASHSP COVID-10 Resource Center.

Adamsick ML, Gandhi RG, Bidell MR, et al. Remdesivir in patients with acute or chronic kidney disease and COVID-19. J Am Soc Nephrol. 2020;31(7):1384-1386.

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.