Pediatric Guidelines: COVID-19

For a PDF version of these guidelines click here.

Click here for comprehensive pediatric COVID-19 and MIS-C management guidelines that incorporate recommendations below. 

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.  

These guidelines are currently focused on specific antiviral, steroid and monoclonal antibody therapies for COVID-19 and do not at this time address supportive care and other aspects of management such as anticoagulation.  

The recommendations below were updated 12/11/2020

Condition 

Major Pathogen(s) 

First Choice Therapy 

Alternative Therapy/(Details) 

Comments 

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 

SARS-CoV-2 

  

  

Supportive care is recommended for most patients.  

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

Monoclonal antibody therapy per Emergency Use Authorizations: 

Bamlanivimab 

OR  

Casirivimab and Imdevimab

Not recommended routinely, may be considered on a case-by-case basis.  

See severe-critical section below if treating with antiviral therapy 

 

ID consultation recommended for any treatment questions in patients hospitalized with COVID-19 

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 

  

  

Age <12 years and/or wt < 40 kg

Remdesivir  lyophilized powder only 

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

Age ≥12 years and wt >40 kg

Remdesivir Injection solution or lyophilized powder 

Wt >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)  

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 (EUA) 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 years 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 consultation recommended  

ID approval is required for 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 guideline. 

  

ID and Rheumatology consults recommended 

References:

Chiotos K, et al. Multicenter interim guidance on use of antivirals for children with coronavirus disease 2019/severe acute respiratory syndrome coronavirus 2. J Pediatr Infect Dis Soc 2020

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 2020 (in press)

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 treatmentsUp to date evidence summary including detail on unsupported therapies. 

Adamsick ML, et al. Remdesivir in patients with acute or chronic kidney disease and COVID-19J Am Soc Nephrol 2020;31:1384-6. 

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. 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 ([email protected]), Pediatric ASP Medical Director at BCH SF and Prachi Singh ([email protected]), Pediatric ASP Medical Director at BCH Oakland.