- 1 9 ISSN 0972-9607

Vol.22 No.2

VID Apr. - Jun. 2020

CO

INDIAN ACADEMY OF

PEDIATRICS
 Subscription Journal of the
Indian Academy of Pediatrics

IJPP Team - 2020

JOURNAL COMMITTEE NATIONAL ADVISORY BOARD

Editor-in-Chief President 2020, IAP
Dr.S.Thangavelu Dr.Bakul Jayant Parekh

Executive Editor President 2021, IAP

Dr.Piyush Gupta
Dr.T.L.Ratnakumari
Editor-in-Chief, IP
Managing Editor
Dr.Devendra Mishra
Dr.G.Durai Arasan
Members
Associate Editors Dr.Ajay Srivastava
Dr.Annamalai Vijayaraghavan Dr.Atul Kulkarni
Dr.S.Lakshmi Dr.Gadadhar Sarangi
Dr.V.Poovazhagi Dr.Gowtham Ghosh
Dr.S.Shanthi Dr.Kiran Makhija
Dr.C.Vijayabhaskar Dr.S.Narmada
Dr.Peeyush Jain
Executive Members
Dr.Sailendra Kumar Das
Dr.R.V.Dhakshayani
Dr.Yogesh Parikh
Dr.S.Kalpana
Dr.M.Zulfikar Ahamed
Dr.K.Senthil Ganesh
Emeritus Editors
Dr.Shanthi Ramesh Dr.A.Parthasarathy
Dr.J.Shyamala Dr.B.R.Nammalwar
Dr.A.Somasundaram Dr.M.Vijayakumar
Dr.Sridevi A Naaraayan Dr.A.Balachandran
Dr.B.Sumathi Dr.K.Nedunchelian
Dr. G.V.Basavaraj Dr.P.Ramachandran
(Ex-officio) Dr.N.C.Gowrishankar
 INDIAN JOURNAL OF
PRACTICAL PEDIATRICS
• IJPP is a quarterly subscription journal of the Indian Academy of Pediatrics committed
to presenting practical pediatric issues and management updates in a simple and clear
manner
• Indexed in Excerpta Medica, CABI Publishing, Scopus
Vol.22 No.2 APR.- JUN. 2020
Dr.S.Thangavelu Dr.T.L.Ratnakumari
Editor-in-Chief Executive Editor

CONTENTS
TOPIC OF INTEREST - “COVID-19 ”
Origin of pandemics 117
- Gouri Rao Passi
Corona virus: What do we know? 121
- Jaydeep Choudhury, Dhanalakshmi K
Pathophysiology of COVID-19: Known and unknown 131
- Suhas V Prabhu
Clinical features and disease stratification of COVID-19 in children 137
- Arun Wadhwa
Neurological aspects of COVID-19 in children 144
- Sheffali Gulati, Juhi Gupta, Priyanka Madaan
Diagnosis of COVID-19 in children 147
- Tanu Singhal
Management of COVID-19 in community and non ICU settings 153
- Sasidaran K, Sheeja Sugunan
Critical care management of pediatric COVID-19 161
- Hari Krishnan Kanthimathinathan, Manu Sundaram, Santosh Sundararajan,
Padmanabhan Ramnarayan, Barnaby R Scholefield
Neonatal COVID-19 172
- Manigandan Chandrasekaran, Amish G Vora
COVID-19: Prevention and education 179
- Sanjay Srirampur, Pritesh Nagar
The role of pediatrician during the pandemic 188
- Ramachandran P, Sunil Srinivasan

Journal Office and address for communications: Dr. S.Thangavelu, Editor-in-Chief, Indian Journal of Practical
Pediatrics, 1A, Block II, Krsna Apartments, 50, Halls Road, Egmore, Chennai - 600 008. Tamil Nadu, India.
Tel.No. : 044-28190032 E.mail : ijpp_iap@rediffmail.com
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Indian Journal of Practical Pediatrics 2020;22(2) : 114

Use of personal protective equipments during COVID-19 pandemic 195

in resource limited settings - The barest minimum needed
- Dhiren Gupta, Simalti AK, Arun Bansal, Neeraj Gupta, Vinayak Patki,
Ashwani Kumar Sood, Anil Sachdev, Bakul Jayant Parekh
Mental health support for patients and professionals 211
- Jayanthini V, Kannan Kallapiran
Social effects of COVID-19 pandemic on children in India 214
- Jeeson C Unni
Preparedness for reopening and conduct of schools during and 217
post COVID-19 period
- Narmada S, Somasundaram A
Guidelines for handling dead body of a COVID-19 patient 223
- Lakshmi S, Kalpana S
GENERAL ARTICLE
Telemedicine - Guidance for pediatric practice 226
- Santhosh MK, Balachander D
RADIOLOGY
Imaging in urinary tract infection 230
- Vijayalakshmi G, Balaji S, Raveendran J, Abirami Mahadevan
CASE REPORT
Challenges encountered in managing non COVID-19 illness during a pandemic 233
- Supraja Chandrasekar, Sindhu Malvel, Gurudutt AV
Unusual presentation of COVID-19 as intussusception 236
- Lalitha Rajalakshmi, Sharada Satish, Nandhini G, Ezhilarasi S

CLIPPINGS 130,143,146,152,160,187,194,210,213,225,229,232,235

FOR YOUR KIND ATTENTION

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- Editorial Board

Published by Dr. S.Thangavelu, Editor-in-Chief, IJPP, on behalf of Indian Academy of Pediatrics, from 1A, Block II,
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Indian Journal of Practical Pediatrics 2020;22(2) : 115

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Indian Journal of Practical Pediatrics 2020;22(2) : 117

COVID - 19

ORIGIN OF PANDEMICS novel infectious diseases burgeoning over time?

Jones et al., analyzed a database of 335 infectious disease
*Gouri Rao Passi outbreaks between 1940 and 2004. They found that
Abstract: The incidence of infectious disease outbreaks outbreaks have risen significantly over time after taking
is increasing over time. This article presents an overview care of reporting bias. Importantly, 60.3% are zoonoses
of some major pandemics. The majority of them are and the vast majority (71.8%) originated in wildlife.
zoonoses and the causes underlying spillovers to humans They also identified certain global ‘hotspots’ where they
are analysed. Degradation of wild life habitats, intensive are most likely to begin.2
animal husbandry and changing land use are some A careful analysis of the influenza epidemics sets the
important causes. The concept of “One Health” is stage for a deeper understanding of why diseases sometimes
highlighted. go out of control. In the last 100 years there have been
4 major pandemics in humans -”Spanish” influenza,
Keywords: Pandemics, Wild life, One health.
H1N1 (1918), “Asian” influenza, H2N2 (1957),
Currently, the world is in the throes of a pandemic of “Hong Kong” influenza, H3N2 (1968) and Swine flu
unprecedented magnitude. Looking back sometimes not Mexico/USA, H1N1 (2009). The deadliest was the Spanish
only clarifies the future and also helps us to look forward flu which killed 40 million people and infected a third of
with confidence into the future. the world’s population between 1918-1919.3 Genetic testing
and phylogenetic analysis of the influenza viruses from
History books abound with tales of pandemics. the fixed and frozen lung tissue of the 1918 epidemic
A prominent story is that of the Black Death. In October victims have revealed that it originated from avian influenza
1340 AD, twelve trading ships from Central Asia, weighed viruses.
anchor in the Sicilian port of Messina. Port authorities
panicked when they found most of the sailors on board Repeated investigations have shown that the natural
dead and the rest afflicted by a terrifying new disease. reservoir of influenza viruses are wild water fowls.
They had nodules breaking out using blood and pus. But these viruses regularly undergo antigenic drift and shift.
Though the ships were ordered to summarily leave, it was The drift is due to mutations in the single stranded RNA of
too late. The infection had set foot in Europe and in five the virus. Because the RNA polymerase of these viruses
years a third of Europe’s population was wiped out. lacks proof reading capacity, all RNA viruses are prone to
multiplicative errors. The antigenic drift helps the virus
This was the bubonic plague, caused by Yersinia evade host immunity and is responsible for annual
pestis. Its natural reservoir is the rat but other animals like outbreaks. However, pandemics occur due to antigenic
dogs, cats and camels can also be infected. The vector shifts. The influenza virus has two viral proteins, namely
which transmits it from rat to rat is the flea. Poor sanitary hemagglutinin (HA) and neuraminidase (NA) which get
conditions and congested surroundings set the stage for attached to the sialic acid on the human epithelial cells
spillover to humans. On a positive note, the plague glycoprotein. They have alpha-2,6 residues while birds have
pandemics led to the birth of widespread public health alpha-2,3 residues. Interestingly, pigs have both.
measures and the first example of quarantine.1 As influenza virus has a segmented genome, pigs act as
reassortment vessels where genes of avian influenza viruses
An important question haunts mankind today.
mix resulting in antigenic shifts and develop capability to
Are pandemics just random events or is the incidence of
infect humans by reassortment.4
* Consultant,
Department of Pediatrics, The innovative influenza virus is relentlessly evolving
Choithram Hospital & Research Centre, new strategies to infect humans and the humans are fighting
Indore. back. In 1997 a global web-based surveillance system called
email: gouripassi@hotmail.com FluNet was established. Data of the various influenza
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Indian Journal of Practical Pediatrics 2020;22(2) : 118

subtypes isolated is continually entered here by various traditional slash and burn cultivation triggered huge fires.
countries. According to data collected, vaccines effective A severe haze enveloped the entire surrounding areas.
against the predicted strains are annually manufactured just Forest trees failed to flower and fruit. Unable to feed in
before the flu season. It also predicted pandemics such as the forests, fruit bats had to look towards greener pastures.
the 2009 H1N1 outbreak which was rapidly evaluated and They flocked to cultivated fruit orchards often adjacent to
contained after just a few cases were detected in Mexico pig farms, a burgeoning industry in Malaysia. Pig feed was
and USA. contaminated with bat excrements. The pigs passed it
further to the pig farmers and were an intermediary
In the mid 1990’s, investigations into a mysterious
amplifying host. Pigs exported to Singapore infected
illness which killed horses and their caretakers in Australia
abattoir workers sparking risks of global spread.
identified a new virus called the Hendra virus (HeV).5
A serological study in horses failed to show any significant The epidemic sent shock waves all over South East
antibodies implying that they were not the primary Asia. Abattoirs in Singapore and Malaysia were shut down.
reservoirs. A careful study of 46 animal species finally One million pigs were culled in Malaysia and the rest of
clarified that fruit bats were the reservoirs.6 the pigs were kept under close surveillance.
An international team of virologists, epidemiologists and
When the virus spreads to horses, they not only acted
public health experts were instrumental in finally quelling
as amplifying agents but further spread it to humans.
the outbreak.11
Since then bats have been repeatedly identified as the
reservoir for a series of zoonoses including the Nipah virus, Later, during outbreaks of Nipah in Bangladesh, by
Ebola, SARS-CoV-1 and now the SARS-CoV-2 using infrared cameras, it was revealed that bats whose
(COVID-19).7,8 The extraordinary characteristics of bats natural habitats had been disturbed had started frequenting
need detailing. Bats form the largest aggregation of forest fringes to eat date palm sap. The contamination of
mammals on the planet around up to a million members. the date palm sap which was collected by the village people
They are greatly vilified in common folklore but vital to to make tari (fermented date palm juice) led to transmission
maintaining nature’s balance. They control insect of the virus to humans without any other animal
populations, reseed cut forests, pollinate plants and scatter intermediary.12
nutritious guano to enrich the soil. Less known fact is that
In 2018, prompt action by public health experts and
they act as reservoirs for more than 200 viruses.9
the administration helped to halt the Nipah virus
Their large breeding grounds, long life spans and encephalitis in Kozhikode, Kerala after an outbreak
ability to fly long distances all contribute to harbouring involving 18 people with 88.8% mortality. The virus was
and spreading viruses. There is intense research into why again isolated in bats of neighbouring forests and
bats are such rich reservoirs of viruses. Delay in recruitment transmission occurred probably during cleaning of an
of B and T lymphocytes suggests that the immune system unused bat infested well or perhaps, visits to the forest by
in bats has evolved to favour incomplete viral clearance to the locals.13
evade immune mediated morbidity and mortality.10
The first pandemic of the 21st century was due to
Bats played a crucial role in the occurrence of the SARS- CoV-1 in 2002. The severe acute respiratory
Nipah virus epidemic in Malaysia in September 1998. syndrome (SARS) infected 8422 patients in 29 countries
It began as an unexplained acute febrile encephalitis in with 916 deaths.14 Painstaking epidemiological tracing
pig farmers of Malaysia with a mortality rate of 40%. identified that the first patients were in Guangdong
But a zoonosis was suspected in view of the preceding province of China. A single patient who travelled from there
epidemic of barking cough and encephalitis in pigs in the to Hong Kong and stayed in a hotel on February 22, 2003
same area. Virus isolation in the CSF of patients and fruit managed to infect 10 more people living in the hotel by
bats in nearby orchards and forests helped to piece together aerosols generated. This led to international spread when
the parts of the puzzle.11 It is edifying to note that the story guests flew back home to Canada, Singapore, Hanoi, etc.
started much earlier and natural climatic variations, human The reservoir of the SARS CoV-1 virus was again traced
behaviour, diminishing forest cover, bats, pigs and our to bats. There was probably an intermediary host, either
intensive animal husbandry practices by human all played the Himalayan Palm Civets or raccoon dogs linked to a
a role. live animal market in Shenzhen, China.
In 1997, there was an unusually hot summer due to A closely related outbreak in April 2012 of severe
the El Nino Southern Oscillation effect. In Indonesia the acute respiratory infections in a hospital in Jordan needs
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Indian Journal of Practical Pediatrics 2020;22(2) : 119

mention. Of the 11 people infected, 8 were health care The natural habitats of wild animals are shrinking.
workers and two of them died. In September 2012 the They are being forced to migrate to newer areas often near
etiological agent was identified as a novel corona virus human settlements. The reasons are protean with wanton
and the infection was named the Middle East Respiratory destruction of forests, unprecedented changes in land use,
Syndrome (MERS).15 Subsequently, there were several intensified agricultural practices due to an explosive growth
other small outbreaks in Saudi Arabia as well as certain in human population and their need are just to name a few.21
countries in Europe. In view of the annual Haj pilgrimage Intensive animal husbandry such as poultry farming and
attracting 2 million people from 182 countries, there was pig farming increase the risk of spillover of new viruses
an urgent evaluation for any pandemic potential. from animals.22 Yet another hotspot for spillovers include
Detailed epidemiological studies to find the animal host wet markets where animals are slaughtered in unhygienic
identified that 22.8% of dromedary camels tested in Saudi conditions. Certain diseases like Ebola are linked to hunting
Arabia harboured the virus and camel shepherds were at and eating of wild meat.23
high risk for infection. Mathematical modelling by Breban,
et al showed that the Ro (the number of secondary cases) The rapid spread across countries is linked to the large
was below 1 and hence pandemic potential was low16 and scale movements of people, livestock, food and goods as
this has been borne out with time. Between 2012 and well as ubiquitous air travel due to tourism in today’s
December 2019 about 2502 patients have been infected world. 24 The human population is predicted to cross
with MERS with a case fatality rate of 34.4%.17 10 billion by 2050. It has increased from 1 billion in the
beginning of the 20th century to 6 billion by the turn of the
The details of the current novel SARS-CoV-2 century.2 Urban spaces are overloaded and it takes just a
epidemic is still evolving. Chinese authorities announced spark to unleash a wildfire.
a cluster of pneumonia of unknown etiology on
31st December 2019 in Wuhan province. Most had an Cataloguing problems without contemplating
association with a local sea food market which sold wild solutions is a recipe for disaster. So, what must be done to
animals also. By 7th January 2020, the infectious agent had reduce the risk of further inevitable outbreaks? We need to
been identified as a novel corona virus (2019 nCoV). solve it at many different levels. Public health experts,
Human to human transmission was soon confirmed with a ecologists, scientists, economists and sociologists and all
R0 of 2-3.5.18 Wuhan’s gargantuan population, widespread mankind need to come together.
trade and travel connections and presence of asymptomatic
carriers are some of the reasons for the consequent Short term solutions include monitoring emerging
malignant global spread. The natural reservoir has again infectious diseases in both wild animals and livestock with
been traced to bats with the possible animal intermediary systems such as the Global Early Warning System
being the pangolin.8. (GLEWS) developed by the Food and Agriculture
Organization-World Organisation for Animal Health
Hidden behind each outbreak is an urgent lesson for formerly the Office International des Epizooties (OIE) -
mankind. The recurrent patterns are obvious. Most deadly World Health Organization (FAO-OIE-WHO), streamlining
emerging infectious disease outbreaks are zoonotic in the animal husbandry industry and wet markets,
origin. New outbreaks are inevitable because of the strengthening core public health services, increasing
constant evolution of organisms. Excessive replicative pandemic preparedness and developing a surge capacity
errors in RNA viruses are the reason why they are the to scale up delivery of health interventions, if required.
commonest novel infections to emerge.19
Animals in the wild coexist harmoniously with deadly Long term solutions include conservation of forests,
viruses. The association probably goes back to millions of wild life and other complex ecosystems. The solution lies
years. Nuclear gene analysis has dated bats to the Eocene in the concept of ‘One Health’.25 We need to understand
period 50 million years ago. Viruses which evolved with that the health of humans is inextricably linked to that of
them probably used key cellular receptors some of which all other animals, organisms, plants and the entire
have been conserved in later mammals like humans.20 biosphere. The economy of unjustified overconsumption
Hence, it is easy for viruses to cross infect man. needs questioning. Each one of us has a role in nurturing
the planet.
Finally, one needs to ask - why do spillovers occur
and why are they increasing over time? There are two parts 400 years ago, John Donne rightly said, “No man is
to the problem - ‘the spark’ where the spillover starts and an island. Every man is a piece of the continent. So never
the ‘spread’, determines how it transforms into a pandemic. send to know for whom the bell tolls. It tolls for thee.”
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Indian Journal of Practical Pediatrics 2020;22(2) : 120

Points to Remember Di Ilio C, De Laurenzi V. Bat–man disease transmission:

zoonotic pathogens from wildlife reservoirs to human
• World had constantly faced pandemics, the most populations. Cell Death Discov 2016; 2(1):1-8.
prominent being black death caused by bubonic 10. Brook CE, Dobson AP. Bats as ‘special’ reservoirs for
plague in 1340, causing death of one third of emerging zoonotic pathogens. Trends Microbiol 2015;
European population in a span of five years, which 23(3):172-180.
led to the birth of widespread public health measures 11. Looi LM, Chua KB. Lessons from the Nipah virus outbreak
and the first example of quarantine. in Malaysia. Malaysian J Pathol 2007; 29(2):63- 67.
• Bats have played a crucial role in the appearance of 12. Luby SP, Rahman M, Hossain MJ, Blum LS, Husain MM,
Gurley E, et al. Foodborne transmission of Nipah virus,
many virus epidemics involving, Nipah virus, Ebola,
Bangladesh. Emerg Infect Dis 2006; 12(12):1888-1894.
SARS-CoV-1 and now the SARS-CoV-2 13. Thomas B, Chandran P, Lilabi MP, George B,
(COVID-19). Sivakumar CP, Jayadev VK, et al. Nipah Virus Infection
• Bats not only play a vital role in maintaining nature’s in Kozhikode, Kerala, South India, in 2018: Epidemiology
balance, but also act as reservoirs for more than 200 of an Outbreak of an Emerging Disease. Indian J
viruses. Community Med 2019; 44(4):383-387.
14. Cherry JD, Krogstad P. SARS: The First Pandemic of the
• Hidden in each outbreak is an urgent lesson for
21st Century. Pediatr Res 2004; 50:1-5.
mankind that the natural habitats of wild animals
15. Alimuddin I. Zumla, Ziad A. Memish. Middle East
are shrinking. They are being forced to migrate to respiratory syndrome coronavirus: epidemic potential or
newer areas often near human settlements. a storm in a teacup? Eur Respir J 2014; 43(5):1243-1248.
• Long term solutions include conservation of our 16. Breban R, Riou J, Fontanet A. Interhuman transmissibility
forests, wild life and other complex ecosystems. of Middle East respiratory syndrome coronavirus:
The solution lies in the concept of “One Health”. estimation of pandemic risk. Lancet 2013; 382:694-699.
We need to understand that the health of humans is 17. Park SE. Epidemiology, virology, and clinical fea-tures of
inextricably linked to that of all other animals, severe acute respiratory syndrome-coronavirus-2
(SARS-CoV-2; Coronavirus Disease-19). Clin Exp Pediatr
organisms, plants and the entire biosphere.
2020; 63(4):119-124.
References 18. Abduljalil JM, Abduljalil BM. Epidemiology, genome, and
clinical features of the pandemic SARS-CoV-2: a recent
1. Zeppelini CG, de Almeida AM, Cordeiro-Estrela P.
view. New Microbes New Infect. 2020; 35:100672.
Zoonoses As Ecological Entities: A Case Review of Plague.
2016. PLoS Negl Trop Dis 2016; 10(10):e0004949. 19. Duffy S, Shackleton LA, Holmes EC. Rates of evolutionary
change in viruses: patterns and determinants. Nat Rev
2. Jones KE, Patel NG, Levy MA, Storeygard A, Balk D,
Genet 2008; 9:267-276.
Gittleman JL, et al. Global trends in emerging infectious
20. Teeling EC, Springer MS, Madsen O, Bates P, O’brien SJ,
diseases. Nature 2008; 451(7181):990-993.
Murphy WJ. A molecular phylogeny for bats illuminates
3. Taubenberger JK. The origin and virulence of the 1918
biogeography and the fossil record.Science 2005;
“Spanish” influenza virus. Proc Am Philos Soc 2006;
307(5709):580-584.
150(1):86-112.
21. Keesing F, Belden LK, Daszak P, Dobson A, Harvell CD,
4. Shao W, Li X, Goraya MU, Wang S, Chen JL. Evolution Holt RD, et al. Nature 2010; 468(7324):647-652.
of Influenza A Virus by Mutation and Re-Assortment.
22. Leibler JH, Otte J, Roland-Holst D, Pfeiffer DU,
Int J Mol Sci 2017;18(8):1650-1663.
Soares Magalhaes R, Rushton J, et al. Industrial food
5. YoungPL, Halpin K, Selleck PW, Field H, Gravel JL, animal production and global health risks: exploring the
Kelly MA, et al. Serologic evidence for the presence in ecosystems and economics of avian influenza. Ecohealth
Pteropus bats of a paramyxovirus related to equine 2009; 6(1):58-70.
morbillivirus. Emerg Infect Dis 1996; 2:239-240. 23. Wolfe ND, Daszak P, Kilpatrick AM, Burke DS Bushmeat
6. Middleton D. Hendra virus. Vet Clin North Am Equine. hunting, deforestation, and prediction of zoonotic disease
2014; 30(3):579-589. emergence. Emerg Infect Dis 2005; 11:1822-1827.
7. Field HE. Bats and Emerging Zoonoses: Henipaviruses 24. Cutler SJ, Fooks AR, van der Poel WH. Public health threat
and SARS. Zoonoses and Public Health 2009; 56:278-284. of new, reemerging, and neglected zoonoses in the
8. Zhou P, Yang XL, Wang XG, Hu B, Zhang L, industrialized world. Emerg Infect Dis 2010; 16(1):1-7.
Zhang W, et al. A pneumonia outbreak associated with a 25. Zinsstag J, Schelling E, Wyss K, Mahamat MB. Potential
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270-273. strengthen health systems. Lancet 2005; 366(9503):
9. Allocati N, Petrucci AG, Di Giovanni P, Masulli M, 2142-2145.

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Indian Journal of Practical Pediatrics 2020;22(2) : 121

COVID - 19

CORONA VIRUS: WHAT DO WE KNOW? animal species, a wide variety of diseases for causes.
In chicken, it causes bronchitis and nephrosis.
*Jaydeep Choudhury Manifestations in pigs include gastroenteritis and
**Dhanalakshmi K encephalitis. In dogs, turkeys and calves, enteritis is the
Abstract: Coronavirus causes a wide variety of diseases usual presentation. While hepatitis and encephalitis in rats,
in various animal species. It is known to cause innocuous peritonitis in cats, pneumonia and hepatitis in whales of
respiratory infections and occasional viral diarrhea in the deseases in defferent specious. It has got varied
humans. Pandemic caused by SARS-CoV-2 (a beta corona manifestations in bats with multiple strains.1 Recent
virus) is a third spill over in two decades of an animal available literature is reviewed for better understanding of
corona virus to humans. It uses ACE2 receptors for cell the nature of virus and viral dynamics which will be useful
entry. Active viral replication has been proved in the cells for improving clinical care and containment of the disease.
of human respiratory tract, conjunctiva and Human corona viruses
gastrointestinal tract contributing to multiple routes of
transmission. Peak viral load is noted at the time of Coronaviruses are medium to large enveloped RNA
presentation which explains the transmission even in pre- viruses. It has a characteristic widely spaced, petal shaped
symptomatic stage. RO is expected to be around 2 to 3, which surface projections, making the virus look like solar corona.
explains the higher pandemic potential. The virus persists The viruses are heat labile and also vulnerable to lipid
on inanimate objects for a variable period of time solvents and alkaline pH.
depending on the infectious dose, temperature and
Coronavirus is positive sense, single stranded RNA
humidity.
of 30 kilobases in length. (Single stranded RNA viruses
Keywords: Coronavirus, Basic reproductive number, Viral are classified as positive or negative depending on the sense
load, Replication sites, Infectivity, Stability. or polarity of the RNA. The positive-sense viral
RNA genome can serve as messenger RNA and can be
The Coronavirus family comprises of two subfamilies, translated into protein in the host cell). It is the largest
Coronavirus and Torovirus. The Coronavirus subfamily is known viral RNA. 2 Structurally a nucleoprotein (N)
divided into four genera, alpha, beta, gamma and delta.
Human Coronaviruses (HCoV) belong to alpha and beta Nucleocapsid protein
genera. Following corona viruses are found to have the
pandemic potential i) SARS-CoV-1, ii) MERS and Envelope
iii) SARS-Cov-2, this is the virus responsible for the current glycoprotein (E)
pandemic. The first HCoV isolation was reported in RNA
1965.The first epidemic of HCoV, Severe Acute
Respiratory Syndrome (SARS) was reported in 2002. Spike protein (S)
Middle East Respiratory Syndrome (MERS) was the next Membrane
major HCoV outbreak which occurred in 2012. In various glycoprotein (M)
Lipid bilayer
* Professor, Department of Pediatrics,
Institute of Child Health,
Kolkata.
** Junior consultant,
Fig.1. Human Coronavirus - Structure
Department of Pediatric Infectious Diseases, Source: Shereen M A, Khana S, Kazmi A, Bashir N,
Kanchi Kamakoti CHILDS Trust Hospital, Siddique R. COVID-19 infection: Origin, transmission, and
Chennai. characteristics of human coronaviruses. J Adv Res 2020;
email: drjaydeep_choudhury@yahoo.co.in 24:91-98.
9
Indian Journal of Practical Pediatrics 2020;22(2) : 122

surrounds the RNA genome and together they appear as a and the infection lasts for about a week. Infection in
coiled tubular helix inside the bilayer lipid envelope, which immune-compromised children may be severe.
anchor membrane (M), envelope (E) and spike (S) protein.
Manifestations of HCoV
A subset of corona viruses (specifically the members of
beta corona virus) have a shorter spike-like surface protein (a) Upper respiratory tract infection: HCoV often presents
called hemagglutinin esterase (HE). like an undifferentiated acute respiratory tract infection.
While replicating, the virus attaches to the cell Rhinorrhea, sore throat, cough, malaise, headache and fever
membrane by HE or S protein in the spikes. Some of the are the usual features.
viruses use angiotensin-converting enzyme 2 (ACE 2) as (b) Lower respiratory tract infection: HCoV is the third
the cellular receptor. Next the penetration occurs due to most common etiology of viral pneumonia and bronchiolitis
fusion of the viral envelope with plasma membrane. A large after respiratory syncytial virus (RSV) and parainfluenza
polyprotein is formed, cleaved into 15 or 16 nonstructural virus. It may also precipitate acute asthma. HCoV may
proteins and a replication complex is formed, following affect neonates and clinically present with apnea, hypoxia
which the transcription is initiated. Virions are assembled and bradycardia.
by budding into cytoplasmic vesicles and released by cell
lysis. (c) Enteric infection: There are reports of nursery outbreaks
of severe diarrhea and necrotizing enterocolitis (NEC)
Epidemiology related to HCoV.1
Coronavirus infection may occur throughout the year, (d) Neurologic diseases: HCoV is linked to neurological
more cases are seen around winter months. It contributes diseases like acute disseminated encephalomyelitis
to about 35% of upper respiratory infection during peak (ADEM), multiple sclerosis and polyradiculitis.
activity. Occasionally there may be outbreaks of infections.
Reinfection is common which may be due to rapid Severe acute respiratory syndrome (SARS)
diminution of antibody level after infection.2 SARS CoV-1 was first identified in China in November
Age 2002 and subsequently it spread throughout the world.
The epidemic lasted till the summer of 2003, the last known
Among patients with common cold across all age case occurred in summer of 2004. It accounted for 774
groups, 2-10% are due to human corona viruses. deaths (9.6% mortality) all over the world.3
Asymptomatic and symptomatic infections occur at all
ages. SARS-CoV was classified as beta coronavirus
lineage B. It originated in animals, most probably bats and
Transmission of HCoV then spread to exotic animals which were consumed by
Infections occur through respiratory route. human in China. Humans were affected subsequently
Aerosols are generated during cough, sneeze or even while through an intermediate host, probably palm civet or
talking. It consists of saliva and nasopharyngeal secretions raccoon dog. The viruses have been noted to mutate
that are contaminated with infectious agents. The droplets frequently and infect new species. SARS-CoV virus was
can be propelled for some distance depending upon their transmitted by aerosols. It uses angiotensin-converting
size and force of expulsion. The expelled droplets can land enzyme as a cellular receptor.2
directly on the conjunctiva, oro-respiratory passage or skin In children, the disease manifested with fever, cough
of a close contact. and systemic influenza like symptoms. Some children had
Small droplets less than 5μm can travel rapidly and diarrhea also.1 Pneumonia developed in few children,
to some distance depending upon the external environment. mostly adolescents. Chest radiology showed ground glass
During dry season with less humidity, the moisture in these opacities with peripheral consolidation. Maternal
particles evaporate to produce droplet nuclei which are light SARS-CoV infection resulted in maternal and fetal
and can remain airborne for a long time. morbidity and mortality.
Respiratory droplets can also contaminate inanimate
Lymphopenia with normal or decreased neutrophil
objects. Touching these objects with contaminated fingers
count is the usual finding in peripheral blood examination.
following cough or sneeze can transmit infection.
Neutrophilia is associated with poor outcome.2 CPK, LDH
In healthy children, HCoV replicates only in the upper and SGOT are usually abnormal. Reverse transcription
respiratory tract. The incubation period is generally 2 days polymerase chain reaction (RT-PCR) specific for
10
Indian Journal of Practical Pediatrics 2020;22(2) : 123

SARS-CoV in respiratory secretions is the confirmatory All MERS-CoV infections were traced to middle east
investigation. There is no specific treatment. Prevention is countries, mainly Saudi Arabia.4,5 Initial transmission
the mainstay. The epidemic was controlled by massive pattern of the virus showed reproductive coefficient (R0)
efforts at case identification and containment. less than 1, which indicates low pandemic potential. Later,
in one outbreak, superspreading was observed where one
Middle east respiratory syndrome (MERS)
patient infected 80 individuals.2 Mean incubation period
The first case of MERS was in Saudi Arabia reported was 5 days with a range of 2 to 14 days.
in June 2012. Later it spread to different parts of the world.
Patients suffering from MERS present with fever,
The virus was named MERS-CoV. Globally it accounted
chills, sore throat, cough, arthralgia and myalgia. They
for 609 deaths (36% mortality).4
often develop dyspnea and rapidly progress to pneumonia.
MERS-CoV was classified as beta coronavirus Many patients required ventilator support. Some presented
lineage C and is closely related to bat coronaviruses. with nausea, vomiting and diarrhea. Renal failure,

Fig 2. Life cycle of SARS CoV2 in host cells (begins its life cycle when S protein binds to the
cellular receptor ACE2. After receptor binding, the conformation change in the S protein
facilitates viral envelope fusion with the cell membrane through the endosomal pathway. Then
SARS-CoV-2 releases RNA into the host cell. Genome RNA is translated into viral replicase
polyproteins pp1a and 1ab, which are then cleaved into small products by viral proteinases.
The polymerase produces a series of sub genomic mRNAs by discontinuous transcription and
finally translated into relevant viral proteins. Viral proteins and genome RNA are subsequently
assembled into virions in the ER and Golgi and then transported via vesicles and released out
of the cell. ACE2, angiotensin-converting enzyme 2; ER, endoplasmic reticulum; ERGIC,
ER–Golgi intermediate compartment).
Source: Shereen MA, Khana S, Kazmi A, Bashir N, Siddique R. COVID-19 infection: Origin, transmission and
characteristics of humancoronaviruses. J Adv Res 2020; 24:91-98.
11
Indian Journal of Practical Pediatrics 2020;22(2) : 124

pericarditis and ARDS have been reported. Children and Box 1. Viral RNA load from upper
adolescents with MERS, occasionally, have been respiratory samples12
asymptomatic or mildly symptomatic.1
Peak on day 4 : 7.11 × 108 copies/swab
Both SARS and MERS have presented with similar Average till day 5 : 6.76 × 105 copies/swab
clinical features. But patients with MERS have a shorter
time from onset of illness to clinical presentation, enhanced Average after day 5 : 3.4×105 copies/swab
requirement for ventilatory support and higher case fatality Viral load from lower respiratory samples (sputum)
rate.4 Maximum viral load : 2.35×109 copies/ml
SARS-CoV-2 Average : 7.00×106 copies/ml

The current pandemic caused by SARS -CoV-2 which Infectivity and replication sites
emerged initially in Wuhan, China is rapidly spreading and
so far has affected 216 countries with 3,00,441 deaths Presence of viral subgenomic mRNA indicates
(as on May 16, 2020).6 It was initially named as 2019 novel actively infected cells since subgenomic mRNA is
coronavirus because of the incomplete match between the transcribed only in infected cells.12 When samples from
genomes of this and other (previously known) the upper respiratory tract were analyzed the presence of
coronaviruses.7 This pathogen was later renamed as severe high viral load proved that active viral replication is
acute respiratory syndrome coronavirus 2 (SARS-CoV-2) happening. Active viral replication was noted till day 5 of
by the Coronavirus Study Group and the disease was named symptom onset and no subgenomic mRNA was identified
coronavirus disease 2019 (COVID-19) by the WHO.8 after that.12
The incubation period of SARS-CoV-2 is estimated to be Similarly, active viral replication from lower
between 1 and 14 days, with a median of 5 to 7 days.9 respiratory samples (sputum) was obvious from Day 4 to
Phylogenetic analysis of the SARS-CoV-2 genome Day 9 (which was evident from the levels of viral
indicates that the virus is closely related (with 88% identity) subgenomic mRNA). Decline in viral load occurred from
to two bat-derived SARS-like coronaviruses collected in Day 10 to Day 11. When analyzing the genotypes from
2018 in eastern China (bat-SL-CoVZC45 and bat-SL- throat and sputum, the presence of genotype distinct
CoVZXC21) and genetically distinct from SARS-CoV serotypes support the fact that viral replication is happening
(with about 79% similarity) and MERS-CoV.7 Even though in the throat rather than shedding of the virus to throat
findings suggest that bats might be the original host of this from lung.12 A recent study showed SARS-CoV-2 infected
virus, further studies are needed to elucidate whether any the ciliated, mucus-secreting, club cells of bronchial
intermediate hosts have facilitated the transmission of the epithelium and alveolar cells in the lung, where gas
virus to humans.7,10 exchange takes place.13 It replicates more effectively in
the bronchi similar to MERS. They also proved infection
Viral dynamics of SARS-CoV-2 and replication of the virus in the conjunctiva and
Viral load from respiratory samples gastrointestinal tract.13 High expression of ACE2 receptors
are also shown in the brush border of intestinal
In an analysis of a cohort of 23 patients with confirmed enterocytes14, 15 and significant titres of virus particles were
COVID-19 infection, peak viral load was highest at the detected. This could explain the subset of patients with
presentation (5.2 log10 copies per ml) even when the disease gastrointestinal symptoms. Thus transmission through eyes
is mild, explaining the high contagiousness of the disease.11 and faeco-oral route serves as additional routes of infection,
Viral load gradually declined over second week. which are relevant for the infection prevention and control.
The relationship between the viral load, severity of the
disease and mortality is yet to be ascertained. The reported Apart from the detection of viral mRNA from
median viral load of 1 log10 was higher in severe cases respiratory samples, stool and conjunctiva, it was also
than mild cases and the difference was not significant.11 isolated from blood, urine and saliva.16-18 From the available
evidence, active viral replication was detected in airways,
In another study from Germany of nine virologically alveolar epithelium, conjunctiva and gastro intestinal tract.
confirmed cases, pharyngeal viral shedding was very high
Duration of viral shedding
during the first week of symptoms (peak at day 4) and
gradually declined (Box 1). The swabs taken after Duration of viral shedding by repeated viral cultures
day 5 had a detection rate of only 39.93% 12 is warranted to ascertain the period of infectivity.
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Indian Journal of Practical Pediatrics 2020;22(2) : 125

Presence of viral mRNA does not always mean active viral Household transmission of SARS-CoV-2
replication and infective potential. SARS CoV-2 RNA has One of the important aspects of the virus transmission
been detected for 20 days or longer in one third of cohorts is its transmissibility among household members. 26
analysed and no association was seen between prolonged The study from Wuhan 19 enrolled 85 patients with
detection of viral RNA and the severity of illness.11 confirmed COVID-19 and their close contacts were 155 in
In an attempt to understand the infectivity and duration total.20 Secondary attack rate was 30% among household
of viral shedding, live virus isolation was attempted members. Among the close contacts, infection rate was 38%
multiple times from various clinical samples.11,12 During for household with 1 contact, 50% for household with
the first week of symptoms, live virus was readily isolated 2 contacts and 31% for households with 3 contacts.20
from significant fraction of samples (16.66% of swabs and Another report, from analysis of cases from
83.33% of sputum).12 After 8 days of symptom onset, 20 provinces outside of Hubei in China found 1183 case
no isolate was obtained from respiratory samples in spite clusters, out of which 64% of the clusters have been within
of ongoing high viral loads. Generally, shedding of viral the familial household.27
RNA from sputum outlasted the onset of symptoms. In most
of the patients where symptoms wane at the end of first Analysing the outbreak in cruise ship Princess
week, viral mRNA was detected from the upper respiratory Diamond off the Japanese coast, where initially 10 people
samples and continued well into the second week and from were confirmed with COVID-19 and all others were
sputum and stool, it can be detected till third week.12 quarantined for 14 days,19% (both passengers and crew)
Considering the above factors, if the patients are clinically were found to be infected when tested later.28,29 Thus, when
stable, home isolation can be offered to those presenting compared with secondary attack rate among the household
after 10 days of symptoms. Understanding this viral contacts for MERS which is 5% and for SARS-CoV which
dynamics is important, because it was insisted that two is 10.2%. The higher secondary attack rate for
negative swabs taken 24 hours apart were needed for SARS-CoV-2 could explain the higher speed of spread and
discharge, but because of this intermittent shedding of viral ever increasing quantity of cases when compared to the
mRNA (which need not be infectious) discharge criteria other two corona viruses.30,31
has been revised.12 Virus survival on different surfaces and
environmental conditions
Basic reproductive number - R0
Though droplet transmission plays a major role in the
To calculate the degree of contagiousness or transmission of SARS-CoV-2, aerosol (particle size <5μm)
transmissibility of the coronavirus (infectivity), and fomite transmission is possible since the virus can
epidemiologists use different mathematical formulae to remain infectious in aerosol for hours and on surfaces
calculate the infectivity index. For this purpose, “basic upto days (depending on the inoculum shed).32 As per the
reproductive number” R0(pronounced as R naught or recent report published, the virus remained viable in
R zero) is used. It is defined as the average number of new aerosol for 3 hours.33 Viruses were applied to different
infections generated by an infectious person in a totally objects, maintained at 21 to 23°C with 40% relative
naïve (uninfected) population.19 It determines the herd humidity over 7 days and time for significant reduction in
immunity threshold and therefore the immunization TCID 50 (Tissue culture infectious dose) was noted.
coverage required to eliminate the disease. If R0 is >1, SARS-CoV-2 is more stable on plastic and stainless steel
the number of people infected is likely to increase and if than on copper and card board. The results are shown in
R0 is <1, transmission is likely to die out. Table I.34
A study from Wuhan reported R0 for SARS-CoV-2 to Stability at different temperatures
be 2.68 based on the imported cases from Wuhan to other
cities.20 A retrospective analysis from 12 different studies, As per another recent work, SARS-CoV-2 is found
quoted an average R0 of 3.28 and median of 2.79. 19 to be highly sensitive to heat and at 4ºC there was only
In general, R0 for COVID-19 is expected to be around around 0.7 log unit reduction on day 14, but at 70º C, the
2 to 3. The difference in R0 in various studies is because of inactivation time was reduced to 5 minutes. 33
different calculation methods and the calculations were They investigated the stability of the virus at 22ºC with a
done during various stages of the epidemic. R0 estimates relative humidity of 65%.Virus stability on various surfaces
by WHO ranges from 2 and 2.5 which is higher than both is given in Table II.34
SARS (1.7-1.9) and MERS (<1), suggesting the higher In a retrospective analysis, human coronaviruses
pandemic potential of SARS CoV -2.21-25 persist for a short time at temperature of 30°C or more.35
13
Indian Journal of Practical Pediatrics 2020;22(2) : 126

Table I. Virus stability on surfaces (21 to 230C with 40% humidity for 7 days) incubated at 21
to 230C and 40% relative humidity over 7 days)34
Surfaces Time for significant reduction in viral titres Reduction in TCID50
Plastic 72 hours 103.7 to 100.6 per milliliter of medium
Stainless steel 48 hours 103.7 to 100.6 per milliliter of medium
Copper 4 hours No viable virus was detected after 4 hours
Card board 24 hours No viable virus was detected after 24 hours
Aerosol 3 hours 10 3.5 to 102.7 TCID 50 per litre of air

Thus the stability of the virus varies under different exposure time.32 WHO recommends 70% ethyl alcohol to
environmental conditions such as varying temperatures and disinfect small surface areas and equipment between usage
humidity. In tropical countries like India with temperature such as reusable equipment (e.g.thermometer).
nearing 40°C during summer and with average humidity
Immunogenicity
of 60-70%, the viral survival on different surfaces needs
to be studied. IgM and IgG antibodies against SARS-CoV -2 internal
nucleoprotein (NP) and surface spike protein receptor
Environmental contamination in health care binding domain (RBD) correlated with neutralising
premises
activity.11 There are many factors which affect the antibody
Many health care workers are affected by COVID-19 production including age, nutritional status, severity of the
and hospitals are becoming the epicenter for human-to- disease, certain medications or infections like HIV which
human transmission. Recently, in a field investigation suppress the immune system.36-38 Antibody levels do not
surface swabs were collected in various hospital correlate with clinical course or disease severity. 11
environments and they were analyzed for the presence of Seroconversion occurred after 7 days in 50% and by day
SARS-CoV-2 RNA. The most contaminated objects were 14 in majority of the patients.12 SARS-CoV-2 infections
self service printers (20.0%), desktop/keyboard (16.8%) are somewhat unusual because IgM and IgG antibodies
and door knobs (16%). Among personal protective arise nearly simultaneously in serum within 2 to 3 weeks
equipments, hand sanitizer dispensers (20.3%) and gloves after illness onset. Thus, detection of IgM without IgG is
(15.4%) were the most contaminated objects.32 uncommon.39 In some patients with confirmed COVID-19
disease by RT-PCR, antibody responses were weak, late
Frequently touched surfaces in the health care settings or absent.37,38,40 Antibodies may also cross react with other
are therefore a potential source of virus transmission. human coronaviruses.37,41,42.
Hence, to decrease the viral load in frequently touched
Because of the variable sensitivity and specificity,
surfaces in the immediate patient surroundings, appropriate
antibody testing cannot be used to diagnose COVID-19.
disinfectants should be used. Surface disinfection with
Some clinicians make a presumptive diagnosis of recent
0.1% sodium hypochlorite or 62-71% ethanol significantly
COVID-19 disease in cases where molecular testing was
reduces coronavirus infectivity on surfaces within 1 minute
negative but where there was a strong epidemiological link
Table II. Virus stability on surfaces (22ºC with to COVID-19 infection and paired blood samples
65% humidity)34 (acute and convalescent) showing rising antibody levels.43
Since the appropriate antibody response happens only in
Surfaces Time at which no the recovery phase, use of it for clinical intervention or to
infectious virus was isolated interrupt the disease transmission is minimal. Lastly,
whether detection of antibodies could predict if an
Printing and Tissue paper After 3 hours
individual is immune to reinfection with the COVID-19
Treated wood & cloth Day 2 virus is still under debate and there is no evidence till date
to support this.43
Glass and bank note Day 4
Tests to detect antibody responses to COVID-19 in
Plastic and Stainless steel Day 7 the population will be critical to support the development
14
Indian Journal of Practical Pediatrics 2020;22(2) : 127

of vaccines and for understanding the extent of infection immune, the disease may no longer persist in the
among people who are not identified through active case community.44,45 Herd immunity threshold, in a given
finding and surveillance efforts, the attack rate in the population, is the point where the disease reaches an
population and the infection fatality rate.43 endemic steady state, which means that the infection level
is neither growing nor declining exponentially.
Herd immunity (herd effect, community immunity,
The threshold can be calculated from the effective
population immunity, social immunity)
reproductive number Re, which can be obtained by taking
Herd immunity is a form of indirect protection from the product of basic reproductive number R0 (average
infectious disease that occurs when a large percentage of a number of new infections caused by an infectious case in
population has become immune to an infection. Immunity the susceptible population) and S, the proportion of
can be achieved either through vaccination or by population who are susceptible to the infection. R0 is a
contracting the infection and over a period of time natural measure of contagiousness, so low R0 values are associated
immunity develops. When a significant proportion of the with lower HITs, whereas higher R0 values result in higher
population are immune, the spread of the disease slows HITs.45,46 For example, if the R0 is 2, the HIT for a disease
down or stops thereby providing a measure of protection is theoretically only 50%, whereas a disease with an R0 of
for individuals who are not immune. 10 the theoretical HIT is 90%.45

Some individuals cannot become immune because of The estimated R0 and HIT of various infectious
their underlying immunodeficiency state or because of diseases is listed on Table III.
immunosuppressive medications and for this group of When the effective reproduction number (Re) is
individuals, herd immunity offers protection. Newborn reduced to below 1 new individual per infection, the
infants also cannot be vaccinated, because of their immature number of cases occurring in the population gradually
immune system and also the acquired antibodies from decreases until the disease has been eliminated.45,46,47 If the
mother renders the vaccine ineffective. Once the herd Re increases to above 1, the disease is actively spreading
immunity reaches a threshold, it helps in elimination of through the population and infecting a larger number of
the disease and if the elimination was achieved globally, it people than usual.43-46 If a population is immune in excess
results in disease eradication. of that disease’s HIT, the number of cases reduces at a
Herd immunity threshold (HIT) or herd immunity faster rate.47,48 So far, eradication programs based on the
level (HIL) concept of herd immunity with reliance on vaccines have
been globally successful in the case of smallpox and
When a critical proportion of the population becomes rinderpest, and are currently underway for poliomyelitis.49

Table III. Estimated R0 and HIT of various infectious diseases22,50-54

Disease RO HIT
Measles 12-18 92-95%
Pertussis 12-17 92-94%
Diptheria 6-7 83-86%
Rubella 6-7 83-86%
Small pox 5-7 84-86%
Polio 5-7 84-86%
Mumps 4-7 75-86%
Influenza (influenza pnademics) 1.5-1.8 33-44%
Ebola (out break in West Africa) 1.5-2.5 33-60%
SARS (2002-2004 out break) 2-5 50-80%
COVID-19 (COVID-19 pandemic) 1.4-3.9 29-74%

15
Indian Journal of Practical Pediatrics 2020;22(2) : 128

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14. Lamers, MM, Beumer J, van der Vaart J, Knoops K, 28. Rocklöv J, Sjödin H, Wilder-Smith A. COVID-19 outbreak
Puschhof J, Breugem TI, et al. SARS-CoV-2 productively on the Diamond Princess cruise ship: estimating the
infects human gut enterocytes. Science 10.1126/ epidemic potential and effectiveness of public health
science.abc1669 (2020). countermeasures. J Travel Med 2020 Feb 28.
15. Yu Zhao, Zixian Zhao, Yujia Wang, Yueqing Zhou, Yu Ma, 29. NHK. Confirmed 947 infection of 2019 novel coronavirus
Wei Zuo, et al. Single cell RNA expression profiling of in Japan. www3.nhk. or.jp/news/special/coronavirus/.
ACE2 , the receptor of SARS-CoV-2. BioRxiv Jan 2020. Date last updated: March 1 2020.
https://doi.org/10.1101/2020.01.26.919985. 30. Drosten C, Meyer B, Müller MA, Corman VM,
16. He Y, Wang Z, Li F, Shi Y. Public health might be Al-Masri M, Hossain R, et al. Transmission of MERS-
endangered by possible prolonged discharge of coronavirus in household contacts. N Engl J Med 2014;
SARS-CoV-2 in stool. J Infect 2020; 80(5):E18-E19. 371(9):828-835.
17. Young BE, Ong SW, Kalimuddin S, Low JG, Tan SY, 31. Wilson-Clark SD, Deeks SL, Gournis E, Hay K, Bondy S,
Loh J, et al. Epidemiologic features and clinical course Kennedy E, et al. House- hold transmission of SARS, 2003.
of patients infected with SARS-CoV-2 in Singapore. JAMA CMAJ 2006; 175(10):1219-1223.
2020; 323(15):1488-1494. 32. Ye G, Lin H, Chen L, Wang S, Zeng Z, Wang W, et al.
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19. Liu Y, Gayle A, Wilder-Smith JR A. The reproductive
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coronavirus. J Travel Med 2020; 27(2):taaa021. doi:10. 33. Doremalen NV, Bushmaker T, Morris DH, Holbrook MG,
1093/jtm/taaa021. Gamble A, Williamson BN, et al. Aerosol and Surface
Stability of SARS-CoV-2 as compared with
20. Wang Z, Ma W, Zheng X, Wu G, Zhang R. Household SARS-CoV-1. N Engl J Med 2020; 382:1564-1567.
transmission of SARS-CoV-2. J Infect 2020;10:28.
34. Chin A, Chu J, Perera M, Hui K, Yen HL, Chan M, et al.
21. World health organization. Report of the WHO-China Joint Stability of SARS-CoV-2 in different environmental
Mission on Coronavirus Disease 2019 (COVID-19). conditions. Lancet Microbe 2020;1(1):E10.
https://www.who.int/docs/default-source/coronaviruse/
35. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence
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of corona viruses on inanimate surfaces and their
Accessed 16th Feb, 2020.
inactivation with biocidal agents. J Hosp Infect 2020;
22. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. 104(3): 246-251.
Early transmission dynamics in Wuhan, China, of novel
36. Zhao J, Yuan Q, Wang H, Liu W, Liao X, Su Y, et al.
coronavirus-infected pneumonia. N Engl J Med 2020;
Antibody responses to SARS-CoV-2 in patients of novel
382(13):1199-1207.
coronavirus disease 2019. Medxriv. Clin Infect Dis 2020.
23. Chen J. Pathogenicity and transmissibility of 2019-nCoV- ciaa344, https://doi.org/10.1093/cid/ciaa344.
A quick overview and comparison with other emerging 37. Okba NA, Muller MA, Wentao Li, Wang C,
viruses. Microbes Infect 2020; 22(2):69-71. GeurtsvanKessel CH, Corman VM, et al. SARS-COV-2
24. Wu JT, Leung K, Leung GM. Now casting and forecasting specific antibody responses in COVID-19 patients.
the potential domestic and international spread of the 2019- Medxrix. 2020; https://www.medrxiv.org/content/10.1101/
nCoV outbreak originating in Wuhan, China: a modelling 2020.03.18.20038059. Accessed on 31st May, 2020.
study. Lancet 2020; 395(10225):689-697. 38. Gorse GJ, Donovan MM, Patel GB. Antibodies to
25. Liu T, Hu J, Kang M, Lin L, Zhong H, Xiao J, et al. coronaviruses are higher in older compared with young
Transmission dynamics of 2019 novel coronavirus (2019- adults and binding antibodies are more sensitive than
nCoV). BioRxiv. January 2020. https:// doi.org/10.1101/ neutralizing antibodies identifying coronavirus - associated
2020.01.25.919787. illnesses. J Med Virol 2020; 92(5):512-517.
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39. Interim Guidelines for COVID-19 Antibody Testing | CDC 47. Dabbaghian V, Mago VK. Theories and Simulations of
www.cdc.gov/coronavirus/2019-ncov/lab/resources/ Complex Social Systems. Springer 2013; pp134-135.
Accessed on 31st May, 2020. 48. Garnett GP. “Role of Herd Immunity in Determining the
40. Lin D, Liu L, Zhang M, Hu Y, Yang Q, Guo J, et al. Effect of Vaccines against Sexually Transmitted Disease”.
Evaluation of serological tests in the diagnosis of 2019 The Journal of Infectious Diseases 2005; 191(1):S97-106.
novel coronavirus (SARS-CoV-2) infections during the 49. Fine P, Eames K, Heymann DL. “Herd immunity”:
COVID-19 outbreak. Medxriv. 2020; https://doi.org/ A rough guide”. Clin Infect Dis 2011; 52 (7):911-916.
10.1101/2020.03.27.20045153. 50. Unless noted, R 0 values are from: History and
41. Wang N, Li SY, Yang XL, Huang HM, Zhang YJ, Epidemiology of Global Smallpox Eradication Archived
Guo H, et al. Serological Evidence of Bat SARS-Related 2017-03-17 at the Wayback Machine From the training
Coronavirus Infection in Humans, China. Virol Sin 2018; course titled “Smallpox: Disease, Prevention, and
33(1):104-107. Intervention”. The Centers for Disease Control and
Prevention and the World Health Organization. Slide 17.
42. Che XY, Qiu LW, Liao ZY, Wang YD, Wen K,
51. Biggerstaff M, Cauchemez S, Reed C, Gambhir M,
Pan YX, et al. Antigenic cross-reactivity between severe
Finelli L. Estimates of the reproduction number for
acute respiratory syndrome-associated coronavirus and
seasonal, pandemic and zoonotic influenza: A systematic
human coronaviruses 229E and OC43. J Infect Dis 2005;
review of the literature. BMC Infect Dis 2014;14:480.
191(12):2033-2037.
52. Wallinga J, Teunis P. “Different epidemic curves for severe
43. WHO. Advice on the use of point-of-care acute respiratory syndrome reveal similar impacts of
immunodiagnostic tests for COVID-19: Scientific brief, control measures”. Am Jl of Epidemiol 2004; 160(6):
April 2020. https://www.who.int/news-room/ 509-516.
commentaries/detail/advice-on-the-use-of-point-of-care-
53. Riou J, Althaus CL “Pattern of early human-to-human
immunodiagnostic-tests-for-COVID-19" https://www.who.
transmission of Wuhan 2019 novel coronavirus (2019-
int/news-room/commentaries/detail/advice-on-the-use-of-
nCoV), December 2019 to January 2020”. Euro Surveill
point-of-care-immunodiagnostic-tests-for-COVID-19.
2020; 25 (4):2000058.
(Accessed on 8th April, 2020).
54. Althaus CL. “Estimating the Reproduction Number of
44. Somerville M, Kumaran K, Anderson R. Public Health Ebola Virus (EBOV) During the 2014 Outbreak in West
and Epidemiology at a Glance. 2nd edn; John Wiley & Sons; Africa”. PLOS Currents 2014; 6.
2012; pp58-59. 55. Altmann DM, Douek DC, Boyton RJ. What policy makers
45. Rodpothong P, Auewarakul P. “Viral evolution and need to know about COVID-19 protective immunity.
transmission effectiveness”. World J Virol 2012; 1(5): The Lancet 2020; 395(10236):p1527-1529.
131-134. 56. Tan W, Lu Y, Zhang J, Wang J, Dan Y, Tan Z, et al.
46. Perisic A, Bauch CT. “Social contact networks and disease Viral kinetics and antibody responses in patients with
eradicability under voluntary vaccination”. PLoS Comput COVID-19. medRxiv2020; https://doi.org/ 10.1101/
Biol 2009; 5(2):e1000280. 2020.03.24.20042382.

CLIPPINGS

Seroprevalence of novel coronavirus disease (COVID-19) in Kobe, Japan.

A cross-sectional serologic testing for SARS-CoV-2 antibody was done on 1,000 samples from patients at
outpatient settings who visited the clinic from March 31 to April 7, 2020, stratified by the decade of age and sex.
There were 33 positive IgG among 1,000 serum samples (3.3%, 95%CI: 2.3-4.6%). By applying this figure to
the census of Kobe City (population: 1,518,870), it is estimated that the number of people with positive IgG be
50,123 (95%CI: 34,934-69,868). Age and sex adjusted prevalence of positivity was calculated 2.7% (95%CI:
1.8-3.9%) and the estimated number of people with positive IgG was 40,999 (95% CI: 27,333-59,221).
These numbers were 396 to 858 fold more than confirmed cases with PCR testing in Kobe City.
Conclusions: This cross-sectional serological study suggests that the number of people with seropositive for
SARS-CoV-2 infection in Kobe, Japan is far more than the confirmed cases by PCR testing.
Doi A, Iwata K, Kuroda H, Hasuike T, Nasu S, Kanda A. Seroprevalence of novel coronavirus disease
(COVID-19) in Kobe, Japan.medRxiv Preprint. May 1, 2020. https://doi.org/10.1101/2020.04.26.20079822.

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Indian Journal of Practical Pediatrics 2020;22(2) : 131

COVID - 19

PATHOPHYSIOLOGY OF COVID-19: mechanisms of damage caused by the virus and the

KNOWN AND UNKNOWN disruption of the host systems, which can explain the
clinical features of the disease and may help in finding
Suhas V Prabhu appropriate treatment modalities. However, since this is a
new disease, few well documented studies are available.
Abstract: The corona virus disease 2019 caused by severe
With the rapid spread and high morbidity and mortality
acute respiratory syndrome corona virus-2 starts as a
associated with this pandemic, the efforts of researchers
respiratory infection but can progress to multi-organ
and clinicians have naturally been focused on risk
involvement with some very unique and unusual clinical
stratification, prevention of transmission, treatment
presentations. This can appear at times puzzling and can
methods and of course the race to find a vaccine. It is but
account for significant morbidity and mortality.
natural that there are very few peer reviewed published
Understanding the pathophysiology of this disease can help
studies on the pathophysiology or autopsy findings of this
reveal the various mechanisms of the progress of the disease
novel disease. It is an evolving field and hence including
and can explain the clinical symptoms and offer hope for
the phrase “Known and Unknown” in the title is justified.
prevention and treatment modalities.
The pathophysiology of the disease has several facets
Keywords: SARS-CoV-2, COVID-19, Pathophysiology,
but essentially the disease occurs in three stages (Fig. 1).
Children.
Stage I. Entry of the virus and early replication
The severe acute respiratory syndrome corona
virus-2 (SARS-CoV-2) that originated in China towards During the first week, when the virus gets inoculated,
the end of December 2019 has spread rapidly all over the it establishes itself inside the host. The route of infection
world and hence labelled as the corona virus disease 2019 is through the mucosa, usually of the upper respiratory tract.
(COVID-19) pandemic. This virus belongs to the Corona The conjunctiva is also a suspect portal of entry.
group, which commonly causes minor upper The virus is believed to gain entry by attachment to a
respiratory tract infections in both children and adults. metallo-peptidase named angiotensin-converting enzyme
The SARS-CoV-2 however is a new mutant with specific receptor (ACE2 receptor). Studies on the earlier SARS
features which are different from the other Corona viruses. virus had shown that the S1 domain of the spike protein of
These are: the virus binds well to the ACE2 receptor.1 In fact, the
SARS-CoV-2 virus has a 10-20 times higher affinity to
1. A novel mutation increasing susceptibility (that makes
these receptors compared to the earlier SARS virus.
practically every human susceptible).
This receptor has therefore been described as the functional
2. An easy transmissibility (that has caused rapid spread receptor for SARS-CoV-2. It is uncertain whether the
worldwide). SARS-CoV-2 virus has any other receptor for entry.
CD209L has been proposed as an alternative receptor, but
3. An unusual pathophysiology with involvement of
confirmation is lacking.2
many systems of the body beyond the respiratory tract
(that has contributed to different clinical presentations The importance of this hypothesis is that drugs that
and higher morbidity and mortality). alter the receptor to prevent attachment by the virus can be
The focus here is to elaborate on the third feature i.e., potentially used in the prevention and treatment of
the unusual pathophysiology. It offers an insight into the COVID-19. Examples of drugs that can change the
glycosylation of these receptors and reduce viral entry in
* Visiting Consulting Pediatrician, vitro are chloroquine and hydroxychloroquine (HCQ) and
P.D. Hinduja Hospital & Medical Research Centre, an initial small uncontrolled study with HCQ had shown
Mumbai. clinical promise.3-5 Although the genes for the ACE2
email : suhaspra@hotmail.com receptor are present in all human cells, they are expressed
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Indian Journal of Practical Pediatrics 2020;22(2) : 132

Fig.1. Stages of COVID-19 infection

only in specific tissues of the body and in high amounts in ACE2 receptors are also expressed in the arterial,
the oral and nasal mucosa and the gastro-intestinal venous endothelial cells and arterial smooth muscles of
epithelium. This is the reason why the virus is easily able organs like heart, liver and brain and these can be affected
to enter the human host through these routes. Once attached, by the infection.1 The testis is another particular organ with
the virus is able to enter the cells by a process of high levels of ACE2 receptors. They possibly serve as a
endocytosis. In vitro electron microscopy studies clearly reservoir for the virus which accounts for the delayed
show hundreds of viral particles clustered around the cilia clearance and higher mortality seen in males compared to
and in double walled vacuoles within the cytoplasm of females. Another reason could be the higher expression of
epithelial cells derived from the respiratory tract. ACE2 receptors in males compared to females. 6
Some studies have also shown that pre-existing heart
Another very remarkable finding is the surface disease leads to a higher expression of ACE2 receptors on
expression of ACE2 protein on lung alveolar epithelial cells the myocardium which may account for the higher cardiac
and in the endothelial cells of arteries and veins in all complications and mortality in this group. This is reflected
organs. This has great relevance to the two important in higher levels of circulating ACE2 receptors in the male
clinical features of the disease i.e. pneumonia and gender especially with pre-existing heart disease like
coagulopathy. Lymphoid cells in the lymph nodes, thymus, cardiac failure.7
bone marrow and spleen are surprisingly devoid of ACE2
so there must be an alternative (but yet unknown) In the first stage of the disease, the virus is just getting
mechanism for the hallmark lymphopenia that is seen even a foothold and multiplying in the mucosa, near the entry
in the early stage of the illness.1 Although the expression site, which is the incubation period and the infected person
of ACE2 metallo-protein in gustatory and olfactory receptor remains asymptomatic. This period lasts from 2 to 7 days
cells has not been specifically studied, it is likely that they with a mean of 4-5 days. The symptoms then start and
are located in the mucosal lining of these organs as they consist of fever (which may be high or even completely
are contiguous. So, they can be invaded by the virus causing absent), constitutional symptoms like headache, body ache,
the two rather specific symptoms of COVID-19 namely dry cough, throat pain, anosmia, ageusia and diarrhoea.
the loss of sensation of smell and taste. The laboratory findings in this stage (that last about a week)
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are lymphopenia, moderately elevated CRP and modest lining may lead to scarring and fibrosis that may present
elevation of LDH. However, some individuals and as ARDS. This can prolong the need for ventilatory support
especially children can remain almost totally asymptomatic into the third week overlapping with the hyperimmune stage
all through the illness. III of the disease with its attendant complications. Recovery
requires a vigorous innate and acquired immune response
Stage II. Spread to lungs and other systems and epithelial regeneration. This may be defective in the
By the second week, the virus is able to spread to the elderly and result in longer duration of sub-optimal lung
lungs which has rich expression of ACE2 receptors and function with consequent very gradual and incomplete
hence pneumonia is the most common pathology. recovery of the lung capacity.
The primary involvement is the ACE2 receptor expressing The pneumonia of COVID is thus different in severity
alveolar type II cells, generally at the periphery of the lung.2 and course from the exudative consolidation seen in
A larger lung alveolar surface area is involved in bacterial infections like pneumococcus. A productive cough
coronavirus infection than in bronchopneumonia, due to therefore is not commonly seen (unless there is a secondary
ubiquitous expression of ACE2 on type II pneumocytes.8 bacterial invasion) and the only symptom may be a
Alveolar type II cells perform many critical functions that progressive shortness of breath with general lethargy and
include production of pulmonary surfactant, airway fatigue from the slowly increasing hypoxia.
epithelial barrier stabilization, immune defence and airway
regeneration in response to injury. As the SARS-CoV-2 Another intriguing observation in COVID-19 disease
replicates within these type II cells, the affected cells is that the hypoxia is not usually accompanied by air
undergo apoptosis and release a large number of viral hunger; instead, a paradoxical feeling of calm and well-
particles to infect the neighbouring cells. Spread to being may result. This phenomenon has been coined ‘silent
surrounding lung is relatively prevented by ciliary activity. or happy hypoxia’. The etiology of this observation is not
clear at present. Certain structural viral proteins attacking
Poor muco-ciliary clearance in the elderly is probably porphyrin moiety of hemoglobin has been postulated as
responsible for the higher incidence of pulmonary a possible reason, but has not been substantiated by
complications in older population. Chronic damage to the evidence.10
ciliary lining of the respiratory tract by habitual smoking
may similarly account for the higher morbidity in smokers. Spread of the virus to many other organs like liver,
Children normally have a robust muco-ciliary action and kidney and brain may start in the second week. This is
are therefore less likely to have COVID pneumonia unless believed to be via the bloodstream and has been
they have pre-existing conditions like cystic fibrosis, documented in Chinese studies. 11 The actual
bronchiectasis or diabetes with consequent reduced muco- pathophysiology in these organs in the current COVID-19
ciliary clearance. This has been validated by clinical data. epidemic has not yet been elucidated as there are no studies
In a multi-centric cross sectional study in North America on histopathology from these organs. Many of the
on 46 children requiring ICU admission, 83% of them had postulates are based on the studies of the earlier SARS
some co-morbidity or pre-existing chronic illness, generally epidemic due to a Corona virus of the same group.
cardio-pulmonary or diabetes mellitus. Twenty four patients In the most comprehensive study of cardiac
(>50%) had one comorbidity, 8 had two and 9 had three or involvement in patients who died from the earlier SARS
more concomitant co-morbidities.9 epidemic, viral RNA was detectable in a third of post-
mortem cardiac tissues and was associated with both
With progressive loss of type II alveolar cells,
decreased ACE2 expression and increased macrophage
surfactant production is affected and micro-atelectasis
infiltration.11,12
occurs causing the streaky shadows seen on chest imaging
by radiography or CT and finally a ground glass Hepatic involvement is common and leads to elevated
appearance. The alveolar type II cells are also the precursors liver transaminases and occasional cases present with
of the type I cells that maintain the integrity of the alveolar jaundice. Neurological symptoms, although uncommon can
lining and permit gaseous exchange. Hence the end result signal invasion of the virus into the CNS and the patient
when the alveolar type I cells get involved is impaired can present with altered sensorium, seizures and
gaseous exchange leading to hypoxia. The pathological neurological deficit. Renal dysfunction is common but this
result of SARS and COVID-19 is diffuse alveolar damage may be as a result of circulatory problems and not due to
with fibrin rich hyaline membranes and a few viral invasion of the kidney. This is buttressed by the fact
multinucleated giant cells. Aberrant healing of alveolar that RT-PCR studies for SARS-CoV-2 in the urine have
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failed to identify the virus.11 Also, changes in these vital Vasculopathy/Coagulopathy: Virchow’s triad delineating
organs would be compounded by problems in blood supply the pathophysiology of intravascular thrombosis proposes
due to cardio-respiratory failure, shock and the that it can occur as a result of three factors: a) reduction in
vasculopathy / coagulopathy. Autopsy findings have shown blood flow (stasis), b) vascular endothelial injury (leading
ischemia, infarction and effects of shock. to triggering of the coagulation cascade) and
c) hypercoagulable state due to alterations in the blood
Surprisingly, many children may have little or no constituents.
respiratory involvement and present with only
All three factors are in part responsible for causing
extra-pulmonary findings. Some have predominant
the reported complications of thrombosis and embolism in
gastro-intestinal symptoms like diarrhea and vomiting, even
COVID-19. The reduced blood flow is secondary to the
intussusception and intestinal gangrene and others have
cardiac decompensation seen as a part of the systemic
only neurological findings like convulsions and altered
inflammation response syndrome (SIRS) or septic shock
sensorium without any cough or dyspnea.12,13 Why this
in severely ill patients. The vascular endothelium is
happens only in the pediatric age group baffles many and
probably damaged directly by the virus via the ACE2
may be related to the different pattern of distribution or
receptors with subsequent triggering of the coagulation
expression of ACE2 receptors.
cascade. Elevated levels of antiphospholipid antibodies
What is also unclear is the rate of resolution of these have been found in some patients with COVID-19 in the
pathological changes in various organs and whether there third week but the correlation with coagulopathy is not
are any residual lesions. This is particularly important in clear. 15 The laboratory evidence for the onset of the
commonly involved organs like the lungs. The reported coagulopathy is the elevation of D-dimer levels which
very gradual recovery of elderly adults with long lasting reflects ongoing activation of the hemostatic and
shortness of breath and dyspnea on minor exertion probably thrombolytic system. Deep vein thrombosis in the lower
indicate an incomplete recovery of normal gas exchange half of the body is the commonest affliction seen followed
in the alveoli due to persistent residual fibrosis. sometimes by pulmonary embolism. Small pulmonary
vessel thrombosis and hemorrhages seen in
Stage III. Hyperimmune response phase SARS-CoV-2 reflect pulmonary involvement and possibly
add to the deranged respiration and gaseous exchange.14
This stage is not seen in all patients. A majority of Part of the CNS and other organ dysfunction may also be
patients and an even higher percentage of children seem to caused by arterial thrombus due to endothelial injury, stasis
recover after stage II or even directly after stage I. and hypercoagulable state.
This has been the case right from the earliest studies from
Intravascular clots in COVID-19 can essentially occur
China. Initial data of 72,314 cases from Wuhan presenting
in any vessel, arterial or venous. Sudden cardiac death seen
for medical care, showed only 1.3% of them were aged
in some adults who appeared to be recovering from
below 20 years and a subsequent report of 171 children
respiratory failure with decreasing oxygen requirement
younger than 16 years hospitalized in Wuhan
could be due to acute myocardial infarction occurring from
province reported that only 3 required ICU care with a
thrombosis in the cardiac circulation. Involvement of these
single fatality. 13-15 Thus, particularly in pediatric age group,
parts of the circulation has been reported to happen more
it is only in a minority of cases where there is a progression
commonly in adults than in children. In contrast, in
to this stage with peculiar features and is possibly related
children, vasculitis/coagulopathy changes have been
to an abnormal or variant host immune response. It is this
described more often in the peripheral circulation like the
stage specific to Corona virus that is responsible for the
tips of the toes and fingers. Lesions such as purpura, skin
severe morbidity and mortality and hence needs to be
necrosis, subcutaneous hematoma and local infarction
addressed. The host immune system comes into play by
causing chilblain like lesions on the tips of the fingers and
the end of the second week or so. This is correlated by the
toes (called “COVID toes”) have been described, initially
presence of IgM antibodies by 5 to 8 days and IgG
from Europe but later on elsewhere too. 16 Clinical
antibodies in a majority of cases by 10-14 days.
importance of this pathophysiology is the possible role of
Further pathophysiology possibly results from a complex
anticoagulants like low molecular weight heparin in
interplay between the direct effects of the virus and the
preventing or treating these complications.
host immune reaction.
Cytokine storm
A few peculiar clinical situations described so far in It is well known that sepsis syndrome complicating
the current COVID-19 epidemic are discussed below. any infection, bacterial or viral is a complex interplay of
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pathogenic effects of the infective agent as well as the host neutrophil functions and have been correlated with a
response. It is no different for COVID-19. While the clinical severe illness.
course of the disease in children may be mild, the immune
iii) The third possibility is that the simultaneous presence
response starting towards the end of the second week can
of other viruses in the mucosa of lungs and airways
contribute to peculiar clinical presentations and contribute
in young children compete with SARS-CoV-2 virus
to mortality. It is quite likely that the resulting organ
and limit its growth. But we do not have studies to
dysfunction is mediated by excessive release of a number
prove this right now.
of cytokines and these are involved in the pathophysiology
of the acute respiratory distress syndrome (ARDS) and the Rather a combination of these factors may cause less
sepsis syndrome described earlier. severe COVID-19 in children.21

But additionally, a specific multisystem inflammatory The pathophysiological mechanisms underlying

syndrome has been described to occur in children with SARS-CoV-2 infection is an unfolding story and the last
COVID-19.17-19 IL-2, IL-6, IL-7, IL-10, granulocytic colony words on the clinical features, pathophysiology and its
stimulating factor (GCSF) and TNF-α are some of the implications for treatment of COVID-19 are yet to be
cytokines with high levels recorded in these cases.20 written. Hence it would be prudent to stay abreast of the
But one of the key cytokines in this process is IL-6 and burgeoning evidence emerging in this long drawn
some studies have shown positive correlation of this agent pandemic.
with disease severity.21 The multisystem inflammatory Points to Remember
syndrome presents with features similar to Kawasaki
• The pathophysiology of SARS-CoV-2 infection
disease with constitutional features, limbus sparing
appears to be unique with involvement of many
conjunctivitis, cracked lips, even skin rashes and brawny
systems of the body beyond the respiratory tract.
edema of peripheries and multi-organ dysfunction including
fluid refractory shock. Hypoalbuminemia and pleural / • The disease progresses through three stages - virus
pericardial effusions have been described in some cases. entry and replication, spread to lungs and other
Laboratory evidence of high acute phase reactant levels organs followed by a hyperimmune response.
(ESR, pro-calcitonin, CRP), IL-6 and ferritin (moderately
elevated) is always present in these cases and markers of • Only a minority of children progress to the
cardiac damage like troponin and N-terminal pro B type hyperimmune response stage.
natriuretic peptide (NT-pro-BNP) may also be elevated. • Vasculopathy / Coagulopathy is responsible for the
Late thrombocytosis, the hallmark of Kawasaki disease is complications of thrombosis and embolism in
however absent. In such a situation, anti-inflammatory COVID-19.
agents like methylprednisolone, intravenous
immunoglobulin and monoclonal antibodies like • Difference in expression level of ACE2 and
Tocilizumab which is specific antagonist for IL-6 have qualitative response to SARS-CoV-2 can explain the
been used with some clinical success.21 clinical differences observed in children.

Several explanations have been proposed for the • Multisystem inflammatory syndrome due to cytokine
relatively lower morbidity and mortality observed in storm may present with features of Kawasaki disease.
children as compared to adults with COVID-19. These References
include the following:
1. Hamming I, Timens W, Bulthuis MLC, Lely AT,
i) The first possibility is that the expression level of Navis GJ, van Goor H. Tissue distribution of ACE2 protein,
ACE2 may differ and ACE2 expression may be lower the functional receptor for SARS coronavirus. A first step
in pediatric population. in understanding SARS pathogenesis.J Pathol 2004;
203(2):631-637. https://doi.org/10.1002/path.1570.
ii) The second possibility is that children have a 2. Mason RJ. Pathogenesis of COVID-19 from a cell biology
qualitatively different response to the SARS-CoV-2. perspective. Eur Resp J 2020; 2000607. doi: 10.1183/
Severe COVID-19 infection in adults is characterized 13993003.00607-2020.
by a massive proinflammatory response or cytokine 3. Keyaerts E, Vijgen L, Maes P, Neyts J, Ranst MV. In vitro
storm that results in ARDS and multi-organ inhibition of severe acute respiratory syndrome coronavirus
dysfunction (MODS). Ageing is associated with by chloroquine. Biochem Biophys Res Commun 2004;
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4. Liu J, Cao R, Xu M, Wang X, Zhang H, Hu H, et al. 13. Cai X, Ma Y, Li S, Chen Y, Rong Z, Li W. Clinical
Hydroxychloroquine, a less toxic derivative of chloroquine, Characteristics of 5 COVID-19 Cases With Non-
is effective in inhibiting SARS-CoV-2 infection in vitro. respiratory Symptoms as the First Manifestation in
Cell Discov 2020; 6(1):1-4. https://doi.org/10.1038/ Children. Front Pediatr, 12th May 2020. doi:10:3389/
s41421-020-0156. fped.2020.00258.
5. Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L, 14. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. Chinese
Mailhe M, et al. Hydroxychloroquine and azithromycin Pediatric Novel Coronavirus Study Team. SARS-CoV-2
as a treatment of COVID-19: results of an open label infection in children. N Engl J Med 2020; 382(17):1663-
non-randomized clinical trial. Int J Antimicrob 1665. doi:10.1056/NEJMc2005073.
Agents 2020;105949. doi:10.1016/j.ijantimicag.
2020.105949. 15. Zhang Y, Xiao M, Zhang S, Xia P, Cao W, Jiang W, et al.
Coagulopathy and Antiphospholipid Antibodies in Patients
6. Zhao Y, Zhao Z, Wang Y, Zhou Y, Ma Y, Zuo W. Single-
with COVID-19. N Engl J Med 2020; 382(17):e38.doi:
cell RNA expression profiling of ACE2, the putative
10.1056 / NEJMc2007575.
receptor of Wuhan 2019-nCov. BioRxiv https://doi.org/
10.1101/2020.01.26.919985. 16. Garcia-Lara G, Linares-González L, Ródenas Herranz T,
7. Sama IE, Ravera A, Santema BT, van Goor H, Ruiz-Villaverde R.Chilblain like lesions in pediatrics
ter Maaten JM, Cleland JGF, et al. Circulating plasma dermatological outpatients during the COVID-19 outbreak.
concentrations of angiotensin-converting enzyme 2 in men Dermatologic Therapy 2020. https://doi.org/10.1111/
and women with heart failure and effects of renin- dth.13516.
angiotensin-aldosterone inhibitors. Eur Heart J 2020: 17. Riphagen S, Gomez X, Gonzalez-Martinez C,
41:1810-1817. Wilkinson N, Theocharis P. Hyperinflammatory shock in
8. McGonagle D, O’Donnel JS, Sharif K, Emery P, children during COVID-19 pandemic. Lancet 2020 May
Bridgewood C. Immune mechanisms of pulmonary 07. [Epub ahead of print].https://www.thelancet.com/
intravascular coagulopathy in COVID-19 pneumonia. journals/lancet/article/PIIS0140-6736(20)31094-1/
Lancet Rheumatol 2020 Published Online May 7, 2020. fulltext.Accessed 9th May, 2020.
https://doi.org/10.1016/ S2665-9913(20)30121-1.
18. Jones VG, Mills M, Suarez D, Hogan CA, Yeh D, Bradley
9. Shekkerdemien LS, Mahmood NR, Wolfe KK, Riggs BJ, Segal J, et al. COVID-19 and Kawasaki disease: novel
Ross CE, McKierman CA, et al. for the International virus and novel case. Hosp Pediatr 2020; hpeds.2020-0123.
COVID-19 PICU Collaborative. Characteristics and doi: 10.1542/hpeds.2020-0123.
Outcomes of Children With Coronavirus Disease 2019
(COVID-19) Infection Admitted to US and Canadian 19. Dhochak N, Singhal T, Kabra SK, Lodha R.
Pediatric Intensive Care Units. JAMA Pediatr. Published Pathophysiology of COVID-19: Why Children Fare Better
online May 11, 2020.doi:10.1001/jama pediatrics. than Adults? [published online ahead of print, 14th May
2020.1948. 2020]. Indian J Pediatr 2020;110. doi:10.1007/s12098-
020-03322-y.
10. Ottestad W, Søvik S. COVID-19 patients with respiratory
failure: what can we learn from aviation medicine? 20. Ye Q, Wang B, Mao J. The pathogenesis and treatment of
[published online ahead of print, 2020 Apr 18]. Br J the ‘Cytokine Storm’ in COVID-19. J Infect. 2020 Apr
Anaesth 2020; S0007-0912(20)30226-9.doi:10.1016/ 10.[Epub ahead of print].https://www.ncbi.nlm.nih.gov/
j.bja.2020.04.012. pmc/articles/PMC7194613/pdf/main.pdf. Accessed 9th
11. Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, et. al. Detection May, 2020.
of SARS-CoV-2 in Different Clinical Specimens JAMA 21. Balasubramanian S, Nagendran TM, Ramachandran B,
2020; 323(18):1843-1844. doi:10.1001/jama.2020.3786. Ramanan AV. Hyper-inflammatory syndrome in a child
12. Oudit GY, Kassiri Z, Jiang C, Liu PP, Poutanen SM, with COVID-19. Treated successfully with intravenous
Penninger JM, et al. SARS-coronavirus modulation of Immunoglobulin and Tocilizumab [published online ahead
myocardial ACE2 expression and inflammation in patients of print, 10 th May2020] Indian Pediatr 2020.
with SARS. Eur J Clin Invest 2009; 39:618-625. S097475591600180.

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Indian Journal of Practical Pediatrics 2020;22(2) : 137

COVID - 19

CLINICAL FEATURES AND across 188 countries and territories, resulting in more than
DISEASE STRATIFICATION OF 3,55,000 deaths and 1.56 million people have recovered
COVID-19 IN CHILDREN too.3

*Arun Wadhwa As COVID-19 is a new disease, many aspects such as

to how it spreads is not proved conclusively. 4
Abstract: We are in the midst of a pandemic caused by The infection is spread during close contact, often by small
novel virus SARS-Cov-2 with no sign of abating. droplets produced during coughing, sneezing, or talking.4
The clinical features have been ranging from asymptomatic The droplets are transmitted and cause new infection, when
to severe respiratory distress leading to death. Fortunately, inhaled by people in close contact (1 to 2 meters / 3-6 feet).
children have been less affected in terms of both morbidity They are also produced during breathing out, but as these
and mortality. Although the signs and symptoms are similar droplets are relatively heavy, they usually fall to the ground
to adults, a smaller number of children tend to be or surfaces.4 Loud talking releases more droplets than
symptomatic. Some children however have been reported normal talking.5 Although not proven crying in children
with unusual skin lesions or vasculitis like syndrome and has also been postulated to release droplets.6
also recently an overlap of Kawasaki and toxic shock like
syndrome named as Pediatric inflammatory multisystem After the droplets fall on floor or surfaces, they can
syndrome, temporally associated with SARS-CoV-2. still infect other people, if they touch these contaminated
The common presentations in children and their difference surfaces and then touch their eyes, nose or mouth with
from adults are discussed. unwashed hands.4 On surfaces, the amount of active virus
decreases over a period of time until it can no longer cause
Keywords: Covid-19, SARS-CoV-2, Clinical features,
infection. However, the virus has been found to survive on
Children.
various surfaces for some time - for example copper or
In the later part of 2019, a novel coronavirus infection cardboard for a few hours, and plastic or steel for a few
emerged in Wuhan, Hubei province, China. It was linked days.7
to animal-to-human transmission in local wet markets.
Subsequently, human-to-human transmission of the virus Sputum and saliva carry large amounts of virus.4,7
commenced, resulting in widespread respiratory illness in Some medical procedures which produce aerosol like
Wuhan and other areas of the Province.1 The virus then dental procedures may result in the virus being transmitted
spread across China and then to other nations across the easier than normal.4,7 Although COVID-19 is not a sexually
globe. On February 11, the World Health Organization transmitted infection, kissing, intimate contact and fecal
named the virus SARS-CoV-2 and the syndrome was oral routes are suspected to transmit the virus.8
named COVID-19, or coronavirus disease 2019. 2
Although not as lethal as the severe acute respiratory The incubation period for COVID-19 is from 2 to
syndrome (SARS) outbreak in 2003, COVID-19 is still 14 days, with an average of 4-6 days. 97.5% of people
characterized by severe respiratory illness and significant who develop symptoms, do so within 11.5 days of
mortality, especially among the elderly and individuals with infection.9 The virus is most contagious during the first
underlying co-morbid conditions such as cardiac and three days after onset of symptoms, spread can occur even
respiratory diseases, diabetes and hypertension.1 As of 28th two days before symptoms appear (pre-symptomatic
May 2020, more than 5.69 million cases have been reported transmission) and in later stages of the disease. A section
of infected people do not develop noticeable symptoms at
* Visiting Consultant, any point of time. These asymptomatic carriers tend not to
Rainbow Children’s Hospital, get tested, and their role in transmission is not yet fully
New Delhi known.10 However, preliminary evidence suggests they may
email id :arun@drwadhwasclinic.com contribute to the spread of the disease.
25
Indian Journal of Practical Pediatrics 2020;22(2) : 138

Symptoms and signs - adults age of patients in the cohort was 48.9 years (57.3%) were
men. 72 potential predictors were evaluated,
Fever is the most common symptom, although some ten variables were found to be independent predictive
older people and those with other health problems factors and were included in the risk score: chest
experience fever later in the disease. In one study, 44% of radiographic abnormality, older age, hemoptysis, dyspnea,
people had fever when they presented to the hospital, while unconsciousness, more number of comorbidities, cancer
89% went on to develop fever at some point during their history, increased neutrophil-to-lymphocyte ratio, elevated
hospitalization.11 lactate dehydrogenase and direct bilirubin. The score has
Other common symptoms include cough, loss of been translated into an online risk calculator that is freely
appetite, fatigue, shortness of breath, sputum production, available to the public (http://118.126.104.170/).
and muscle and joint pains.11 Symptoms such as nausea, Covid-19 in children
vomiting, and diarrhea have been observed in varying
proportions.12 Less common symptoms include sneezing, Pediatric cases of COVID-19 have been reported but
runny nose or sore throat13 (Table I). Some patients in China there are relatively fewer cases among children compared
initially presented with only chest tightness and to adult patients.It was 2% in the United States, 2.2% in
palpitations.14 A decreased sense of smell (hyposmia) or China, 1.2% in Italy and 0.8% in Spain of confirmed cases
disturbances in taste (hypogeusia) may occur.15 Severity who were below 18 years of age.18 Most of the children
of symptoms tend to be more in patients with underlying had exposure to household members with confirmed
medical conditions. COVID-19.
According to Centre for disease control (CDC), The predominant signs and symptoms of COVID-19
Atlanta, USA, people with these symptoms or combinations reported to date among all patients are similar to other viral
of symptoms may have COVID-19: Cough with shortness respiratory infections, including fever, cough and shortness
of breath or difficulty in breathing: Or at least two of the of breath. Although these signs and symptoms may occur
following symptoms: Fever, chills, repeated shaking with at any time during the overall disease course, children with
chills, muscle pain, headache, sore throat, new loss of taste COVID-19 may not initially present with fever and cough
or smell.16 as often as adult patients.18 Data from China suggest that
pediatric COVID-19 cases might be less severe than adults
Risk scoring and that children might experience different symptoms than
In collaboration with the National Health Commission do adults.19,20 These findings are largely consistent with a
of China, and based on a retrospective cohort of report on pediatric COVID-19 patients aged <16 years in
1590 patients with COVID-19 from 575 hospitals, a high- China, which found that only 41.5% of pediatric patients
risk score has been developed for adults.17 The score had fever, 48.5% had cough and 1.8% were admitted to an
provides an estimate of the risk that a hospitalized patient ICU.18 A second report suggested that although pediatric
with COVID-19 will develop critical illness. Critical illness COVID-19 patients infrequently have severe outcomes, the
was defined as the composite measure of admission to the infection might be more severe among infants. The same
intensive care unit, invasive ventilation or death. The mean report detected no substantial difference in the number of
cases among males and females.20

Table I. Symptoms in adults11 Age distribution

Symptoms Range Data from 1,49,760 laboratory-confirmed

COVID-19 cases in the United States occurring during
Fever 83–99%
February 12-April 2, 2020 were analyzed. Among 1,49,082
Cough 59–82% (99.6%) reported cases for which age was known, 2,572
Loss of appetite 40–84% (1.7%) were among children aged <18 years (the median
age being 11 years).21 Nearly one third of reported pediatric
Fatigue 44–70% cases (32%) occurred in children aged 15-17 years,
Shortness of breath 31–40% followed by those in children aged 10-14 years (27%).
Among younger children, 15% occurred in children aged
Coughing up sputum 28–33% <1 year, 11% in children aged 1-4 years and 15% in children
Muscle aches and pains 11–35% aged 5-9 years. Among 2,490 pediatric COVID-19 cases

26
Indian Journal of Practical Pediatrics 2020;22(2) : 139

for which sex was known, 57% occurred in males; among with COVID-19, 147 (estimated range = 5.7%–20%) were
cases in adults aged >18 years for which sex was known, reported to be hospitalized, with 15 (0.58%-2.0%) admitted
53% were males. to an ICU. Among adults aged 18-64 years, the percentages
of patients who were hospitalized (10%-33%), including
Symptoms and signs
those admitted to an ICU (1.4%-4.5%),were higher.
In the same US study, complete data on signs and Whereas most COVID-19 cases in children are not severe,
symptoms of COVID-19 were available for 291 of 2,572 serious COVID-19 illness resulting in hospitalization still
(11%) pediatric cases and 9.6% cases among adults aged occurs in this age group. Children aged <1 year accounted
18-64 years. Among the children with available for the highest percentage (15%-62%) of hospitalization
information, 73% only had symptoms of fever, cough, or among pediatric patients with COVID-19. Among 95
shortness of breath compared with 93% of adults aged children aged <1 year with known hospitalization status,
18-64 years. Among those with known information on each 59 (62%) were hospitalized, including five who were
symptom, 56% of pediatric patients reported fever, 54% admitted to an ICU. The percentage of patients hospitalized
reported cough, and 13% reported shortness of breath, among those aged 1-17 years was lower (estimated range
compared with 71%, 80%, and 43% respectively, reporting = 4.1%-14%), with little variation among age groups.21
these signs and symptoms among patients aged 18-64 years
Among 345 pediatric cases with an underlying
(Table II). Myalgia, sore throat, headache and diarrhea were
condition, 80 (23%) had at least one underlying condition.
also less commonly reported by pediatric patients. 21
The most common underlying conditions were chronic lung
These data support previous findings that children with
disease including asthma 40(50%), cardiovascular disease
COVID-19 might not have reported fever or cough as often
25(31%) and immunosuppression 10(13%). Among the 295
as adults.18
pediatric cases for which information on both
Hospitalization in children hospitalization status and underlying medical conditions
was available, 28 of 37 (77%) hospitalized patients,
Information on hospitalization status was available
including all six patients admitted to an ICU, had one or
for 29% (745 of 2572) cases in children aged <18 years
more underlying medical condition; among 258 patients
and 31% cases in adults aged 18-64 years. Among children
who were not hospitalized, 30 (12%) patients had
Table II. Signs and symptoms among 291 underlying conditions.21 Three deaths were reported among
pediatric (age <18 years) and 10,944 adult the pediatric cases included in this analysis; however,
(age 18–64 years) patients with laboratory- review of these cases is ongoing to confirm COVID-19 as
confirmed COVID-19 - United States, the likely cause of death. In the present analysis, the
February 12–April 2, 202021 predominance of males in all pediatric age groups,
including patients aged <1 year, suggests that biologic
Sign/Symptom No. (%) with sign/symptom factors might play a role in any differences in COVID-19
Pediatric Adult susceptibility by sex.
Fever, cough, or 213 (73) 10,167 (93) In a study of 20 children admitted in Wuhan children’s
shortness of breath hospital during the early part of the pandemic, 7 had a
Fever 163 (56) 7,794 (71) previous history of congenital or acquired diseases, which
may indicate that children with underlying diseases may
Cough 158 (54) 8,775 (80)
be more susceptible to COVID-19 infection.22 It was noted
Shortness of breath 39 (13) 4,674 (43) that the procalcitonin (PCT) was elevated in 80% cases in
this study, with or without coinfection, which was not
Myalgia 66 (23) 6,713 (61)
common in adult patients. Co infection was however noted
Runny nose 21 (7.2) 757 (6.9) in 8/20 (40%) indicating it is probably more common in
Sore throat 71 (24) 3,795 (35) pediatric patients.23

Headache 81 (28) 6,335 (58) Relevance of Pediatric COVID presentation

Nausea/Vomiting 31 (11) 1,746 (16) This preliminary examination of characteristics of
Abdominal pain 17 (5.8) 1,329 (12) COVID-19 disease among children in the United States
and China suggests that children do not always have fever
Diarrhea 37 (13) 3,353 (31) or cough as reported signs and symptoms. Although most
27
Indian Journal of Practical Pediatrics 2020;22(2) : 140

cases reported among children to date have not been severe, minority of them may have had diarrhea or nausea one or
clinicians should maintain a high index of suspicion for two days before the onset of symptoms.
COVID-19 infection in children and monitor for
progression of illness, particularly among infants and Day 5: Patients may have difficulty breathing specially
children with underlying conditions. As persons with if they are older or they have a preexisting health condition.
asymptomatic and mild disease, including children, Day 7 is the average time the patients are admitted.
are likely playing a role in transmission and spread of
COVID-19 in the community, social distancing and Day 8. At this point patients with severe illness
everyday preventive behaviors are recommended for develop ARDS. If the disease worsens patients are generally
persons of all ages to slow the spread of the virus, protect admitted to the ICU by day 10.
the health care system from being overloaded and protect
Day 14-17 is the usual time the patient is discharged
older adults and persons of any age with serious underlying
from the hospital.
medical conditions.11,22
The child has to be restricted from mixing with other
Dermatological manifestations
family members, especially the elderly, during the course
Five skin conditions associated with coronavirus have of the disease and even later. The duration of quarantine
been identified by dermatologists and deserve special can be time based, symptom based or test based. 26
mention. A research carried out on 375 patients in Spain24, The patient should be quarantined for 14 days after
aimed to build a picture of how the disease might manifest recovery. Recovery is when 3 days (72 hours) have passed
with skin symptoms. The Spanish dermatologists were after resolution of fever without the use of fever-reducing
asked to identify patients who had an unexplained skin medications and improvement in respiratory symptoms
“eruption” in the last two weeks and who had suspected or (e.g., cough, shortness of breath) and at least 10 days have
confirmed Covid-19. Five different lesions were identified. passed since symptoms first appeared. In test-based
Lesions were classified as acral areas of erythema with strategy, resolution of fever without the use of antipyretics
vesicles or pustules (Pseudo-chilblain, 9%), other vesicular and improvement in respiratory symptoms (e.g., cough,
eruptions (9%), urticarial lesions (19%), maculopapular shortness of breath) and negative results of at least two
eruptions (47%) and livedo or necrosis (6%). consecutive respiratory specimens collected more than
Vesicular eruptions appear early in the course of the disease 24 hours apart are considered as indicators of recovery.
(15% before other symptoms). The pseudo-chilblain pattern
Disease stratification
frequently appears late in the evolution of the COVID-19
disease (59% after other symptoms), while the rest tend to The decision to manage a pediatric patient with mild
appear with other symptoms of COVID-19. Severity of to moderate COVID-19 in the outpatient or inpatient setting
COVID-19 shows a gradient from less severe disease in should be decided on a case-by-case basis.
acral lesions to most severe in the other groups. Pediatric healthcare providers should consider the patient’s
Results are similar for confirmed and suspected cases. clinical presentation, requirement for supportive care,
Alternative diagnoses were discussed but seem unlikely underlying conditions and the ability for parents or
for the most specific patterns (pseudo-chilblain and guardians to care for the child at home.11
vesicular). These may help clinicians approach patients
with the disease and recognize pauci-symptomatic cases.24 Severe COVID-19 in children is rare. The largest
review of children with COVID-19 included 2143 children
Course of the disease in China. Only 112 (5.6%) of 2143 children had severe
disease (defined as hypoxia) and 13 (0.6%) children
The disease can have a very variable course, from
developed respiratory or multiorgan failure or ARDS.33
asymptomatic to life threatening. All the various
Emergency signs and symptoms include difficulty in
determinants of this variability have not been worked out
breathing, persistent chest pain or pressure, new confusion,
yet. A typical course can be described as below. 25
blue lips or face. If there are any of these signs or symptoms
Symptom onset is preceded by an incubation period from
the child should be admitted immediately. Any child
the day of contact which ranges from 1 to 14 days with
without these symptoms but has a chronic medical
median estimates of 5 to 6 days.
condition such as heart disease, lung disease or on
Day 1: Patients start having fever. They may also chemotherapy should also be admitted.11 Classification
experience fatigue, muscle pain, and a dry cough. A small based on the severity of illness is summarized in Box 1.

28
Indian Journal of Practical Pediatrics 2020;22(2) : 141

In the absence of studies involving large number of

Box.1 Definitions of clinical types of
children and considering the fact that the incidence and as
COVID-19 in pediatric patients38
well as proportion of critically ill children is too little,
Mild disease assessment of physiological status will give a guidance on
disease stratification as given in Box 1 .
• Upper respiratory symptoms (eg, pharyngeal
congestion, sore throat and fever) for a short duration Complications
or asymptomatic infection
Respiratory
• Positive RT-PCR test for SARS-CoV-2
In some people, COVID-19 may cause viral
• No abnormal radiographic and septic presentation pneumonia. In those most severely affected, COVID-19
may rapidly progress to acute respiratory distress syndrome
Moderate disease
(ARDS) causing respiratory failure, septic shock, or multi-
• Mild pneumonia organ failure and death.29 Complications associated with
COVID-19 include sepsis, abnormal clotting and damage
• Symptoms such as fever, cough, fatigue, headache, to the heart, kidney and liver. Approximately 20-30% of
and myalgia people who present with COVID-19 demonstrate elevated
• No complications and manifestations related to liver enzymes more frequently seen in severe cases.30
severe conditions Neurological manifestations include seizures, stroke,
encephalitis and Guillain–Barré syndrome. 31
Severe disease Cardiovascular related complications may include heart
Mild or moderate clinical features, plus any failure, arrhythmias, thrombosis and myocarditis.32
manifestations that suggest disease progression:
Inflammatory syndrome
• Rapid breath (>70 breaths per min for infants aged
A growing number of hospitals in the U.S. and U.K.
<1 year; e”50 breaths per min for children aged >1
have reported cases with presentation similar to Kawasaki
year)
Disease.33 Symptoms of these children include fever, rash,
• Hypoxia eye irritation, swollen lymph nodes and/or swelling of the
hands and feet.The link between Kawasaki syndrome and
• Loss of consciousness, depression, coma,
COVID-19 is still not well established. The UK Kawasaki
convulsions
Disease Foundation released a statement saying that many
• Dehydration, difficulty feeding, gastrointestinal children with the disease tested negative for COVID-19
dysfunction and there is no current evidence of any increased incidence
or greater susceptibility to COVID-19 infection for children
• Myocardial injury who had Kawasaki Disease in the past.34
• Elevated liver enzymes
Though COVID in children presents with milder
• Coagulation dysfunction, rhabdomyolysis and any symptoms and less complications, the hospitalization and
other manifestations suggesting injuries to vital ICU admission are relatively more in infants and those with
organs existing health conditions within the pediatric age group.
The pediatricia has to be aware of certain atypical
Critical illness
manifestations such as dermatological lesions and
Rapid disease progression, plus any other conditions: inflammatory syndromes which may be related to
SARS-CoV-19 infection.
• Respiratory failure with need for mechanical
ventilation (eg, ARDS, persistent hypoxia that cannot Points to Remember
be alleviated by inhalation through nasal catheters
or masks) • Children are less often involved compared to adults.
• The pediatric patients may be asymptomatic or show
• Septic shock
mild non-specific viral symptoms like fever, cough
• Organ failure that needs monitoring in the ICU and cold.

29
Indian Journal of Practical Pediatrics 2020;22(2) : 142

• Some may present with skin lesions or vasculitis. syndrome coronavirus 2 (SARS-CoV-2): Facts and myths.
J Microbiol Immunol infect 2020; 53(3):404-412.
• High index of suspicion is required in view of non- 11. “Interim Clinical Guidance for Management of Patients
specific mild illness in pediatric age group. with Confirmed Coronavirus Disease (COVID-19)”.
• Children less than three years should be carefully Centers for Disease Control and Prevention. Updated 12
monitored for deterioration as they may not be able May 2020. https://www.cdc.gov/coronavirus/2019-ncov/
hcp/pediatric-hcp.html Accessed on 14th May 2020.
to communicate worsening.
12. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al.
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8. “Sex and Coronavirus Disease 2019 (COVID-19)” (PDF). 12-April 02 2020. https://www.cdc.gov/mmwr/volumes/
nyc.gov. 27th March 2020. Accessed on 29th April, 2020. 69/wr/mm6914e4.htm. Accessed on 28th May, 2020.
9. Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, 22. Wei WE, Li Z, Chiew CJ, Yong SE, Toh MP, Lee VJ.
Meredith HR, et al. (March 2020). “The Incubation Period Presymptomatic transmission of SARS-CoV-2-Singapore,
of Coronavirus Disease 2019 (COVID-19) From Publicly January 23-March 16, 2020. MMWR Morb Mortal Wkly
Reported Confirmed Cases: Estimation and Application”. Rep 2020. Epub April 1, 2020. Accessed on 15th April,
Ann Int Med 172(9):577. doi:10.7326/M20-0504. 2020.
Accessed on 29th April, 2020. 23. Xia W, Shao J, Guo Y, Peng X, Li Z, Hu D. Clinical and
10. Lai CC, Liu YH, Wang CY, Wang YH, Hsueh SC, CT features in pediatric patients with COVID-19 infection:
Yen MY, et al. Asymptomatic carrier state, acute respiratory Different points from adults. Pediatric pulmonology 2020;
disease, and pneumonia due to severe acute respiratory 55(5):1169-1174. Accessed on 15th April, 2020.
30
Indian Journal of Practical Pediatrics 2020;22(2) : 143

24. Galván Casas C, Català A, Carretero Hernández G, action/showPdf?pii=S1473-3099%2820%2930198-5.

Rodríguez-Jiménez P, Fernández Nieto D, Rodríguez-Villa Accessed on 25th May, 2020.
Lario A, et al. Classification of the cutaneous manifestations 29. Hui DS, I Azhar E, Madani TA, Ntoumi F, Kock R,
of COVID-19: a rapid prospective nationwide consensus Dar O, et al. “The continuing 2019-nCoV epidemic threat
study in Spain with 375 cases. Br J Dermatol 2020. of novel coronaviruses to global health - The latest 2019
25. A day by day breakdown of Coronavirus symptoms how novel coronavirus outbreak in Wuhan, China”. Int J Infect
the disease, COVID-19, goes from bad to worse. Dis 2020; 91:264-266. doi:10.1016/j.ijid.2020.01.009.
https://www.businessinsider.in/science/news/a-day-by- 30. Xu L, Liu J, Lu M, Yang D, Zheng X. Liver injury during
day-breakdown-of-coronavirus-symptoms-shows-how- highly pathogenic human coronavirus infections.
the-disease-COVID-19-goes-from-bad-to- Liver International 2020; 40(5):998-1004. doi:10.1111/
worse/articleshow/74257460.cms. Accessed on 25th May, liv.14435.
2020. 31. Carod-Artal FJ. Neurological complications of coronavirus
and COVID-19. Revista de Neurologia 2020; 70 (9):311-
26. Return to work criteria CDChttps://www.cdc.gov/
322. doi:10.33588/rn.7009.2020179.
coronavirus/2019-ncov/hcp/return-to-work.html. Accessed
on 28th May 2020. 32. Long B, Brady WJ, Koyfman A, Gottlieb M.
Cardiovascular complications in COVID-19.
27. Sinha IP, Harwood R, Semple MG, Hawcutt DB, The American Journal of Emergency Medicine 2020.
Thursfield R, Narayan O, et al. COVID-19 infection in doi:10.1016/j.ajem.2020.04.048.
children. https://www.thelancet.com/pdfs/journals/lanres/ 33. Bing News.com Covid and Kavasaki Disease. https://
PIIS2213-2600(20)30152-1.pdf. Accessed on 28th May, www.bing.com/news/search? q=Covid+and+kawasaki+
2020. disease and qpvt=covid+and+ kawasaki+disease and
28. Qiu H, WuJ, Hong L, LuoY, Song Q, ChenD. Clinical and FORM= EWRE.
epidemiological features of 36 children withcoronavirus 34. The UK Kawasaki Disease Foundation. Kawasaki Disease
disease 2019 (COVID-19) in Zhejiang, China:an and COVID-19 https://www.societi.org.uk/kawasaki-
observational cohort study. https://www.thelancet.com/ disease-and-COVID-19/. Accessed on 28th May, 2020.

CLIPPINGS

Consensus statement on chest imaging in pediatric COVID-19 patient management: Imaging findings and
imaging study recommendations.
CXR: In the clinical experience of this expert panel of pediatric chest radiologists, both unilateral and bilateral
opacities have been observed in pediatric COVID-19, although bilateral opacities are more typical and may
show patchy opacities with peripheries and lower lung zone predominance. Bilateral peripheral and/or subpleural
ground-glass opacities and/or consolidation are suggestive of COVID-19 pneumonia. However, other viral or
atypical pneumonia would also be differential considerations. Less sensitive than CT in detecting lung
parenchymal opacities. CXR is considered the most appropriate first step in imaging evaluation
CT chest: Bilateral and subpleural ground-glass and/or consolidative opacities often in the lower lobes of lungs.
The “halo” sign, which describes a focal consolidation with a rim of surrounding ground-glass opacity, has been
reported in up to 50% (10/20) of cases. The “halo” sign is generally observed early in the disease course
(early phase) and progresses to ground-glass (progressive phase) and eventually develops into consolidative
opacities (developed phase). Peribronchial thickening and inflammation along the bronchovascular bundle are
observed more frequently in the pediatric population compared to adults. Fine mesh reticulations and crazy
paving sign have also been reported. These CT findings are not pathognomonic. Thus the American College of
Radiology currently recommends against using CT as a first line screening test to diagnose COVID-19 because
of the risk of radiation and states that chest CT should be reserved for symptomatic hospitalized patients with
specific clinical indications.
Foust AM , Phillips GS, Chu WC, Daltro P, Das KM, Peña PG, et al. International Expert Consensus Statement
on Chest Imaging in Pediatric COVID-19 Patient Management: Imaging Findings, Imagings study reporting
and imaging study recommendations. Radiology: Cardiothoracic Imaging Vol. 2, No. 2. Published Online:Apr
23 2020https://doi.org/10.1148/ryct.2020200214.

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Indian Journal of Practical Pediatrics 2020;22(2) : 144

COVID - 19

NEUROLOGICAL ASPECTS OF described neurological manifestations, is also unclear.

COVID-19 IN CHILDREN Two routes of entry into the central nervous system have
been suggested- hematogenous and via the cribriform plate.
*Sheffali Gulati Both direct virus-induced injury and immune-mediated
**Juhi Gupta damage have been thought to underlie the pathogenesis of
***Priyanka Madaan neurological complications.
Abstract: Children with COVID-19 infection may present Neurological manifestations
with various neurologic manifestations. Although several
neurological findings have been documented, it is not clear The neurological manifestations reported with
whether they are causally attributable to SARS-Co-V2 or COVID-19 in children include few reports of paroxysmal
just occur incidentally in children with COVID-19 events (including seizures) over a wide age range
infection. During the epidemic period of COVID-19, when encompassing a newborn and an adolescent with status
seeing patients with neurologic manifestations, clinicians epilepticus.3-5 A premorbidly normal 11 year-old boy
should consider SARS-CoV-2 infection as a differential without any prior history of seizures, presented with status
diagnosis to avoid delayed diagnosis and lose the chance epilepticus. He had a striking absence of typical respiratory
to treat and prevent further transmission. This article symptoms except fever recorded at admission. The status
documents the various neurological features that have been epilepticus required four antiepileptic drugs.
reported till date due to COVID infection in children. Electro-encephalography (EEG) revealed frontal
intermittent delta activity and cerebrospinal fluid
Keywords: Neurological manifestation, COVID -19, examination (CSF) was suggestive of meningitis/
Children. encephalitis.3 His computed tomography (CT) brain was
Children under 19 years of age represented only 2% normal. Similarly, paroxysmal events have been described
of total diagnosed cases of COVID-19 in a large cohort of in a 26 day-old neonate and 6 week-old infant, who
72,314 patients from China.1 While studies in adults report presented with fever and mild respiratory symptoms.4,5
up to 36.4% incidence of neurologic symptoms in Evidence of abnormal EEG and uprolling of eyeballs in
COVID-19, there are no published cohorts describing the infant points towards seizures, however normal EEG
neurological complications of COVID-19 in children with and termination of episode with stimulation raises the
exception of a few case reports / series.2 Moreover, whether suspicion of non-epileptic events in the case of newborn.
severe acute respiratory syndrome coronavirus 2 The CSF examination was normal in these 2 cases.
(SARS-CoV-2) is coincidental or causative for the Whether COVID-19 was the culprit or an incidental
finding in above cases is not clear as neither SARS-CoV-2
* Chief, Child Neurology Division,
Center of Excellence & Advanced Research on
was demonstrated in CSF nor it was the sole pathogen
Childhood, Neurodevelopmental Disorders, detected in the respiratory samples (positive for rhinovirus/
All India Institute of Medical Sciences, New Delhi. enterovirus also in case of infant and adolescent).
** Senior Resident, Child Neurology Division, Another report describes vague findings of axial hypotonia
Department of Pediatrics, with drowsiness, moaning sounds in four infants (<3
All India Institute of Medical Sciences, New Delhi. months) presenting with fever and mild respiratory
*** Senior Research Associate, symptoms.6 Co-existing fever and dehydration suggested
Pediatric Neurology Unit, Department of Pediatrics, by presence of mottled skin (present in 3 out of 4 children)
Advanced Pediatrics Centre, cannot be refuted as possible causes for these non-specific
Post Graduate Institute of Medical Education & signs. Interestingly, all these children had a favorable
Research (PGIMER), Chandigarh. outcome with complete recovery without any antiviral/
email: sheffaligulati@gmail.com immunomodulatory therapy.

32
Indian Journal of Practical Pediatrics 2020;22(2) : 145

Similar to adults, neurologic manifestations such as children with infantile spasms, Duchenne muscular
dizziness, headache, encephalopathy, myositis, taste and dystrophy (DMD), etc. Current guidelines advocate
smell impairment, etc. may be seen in adolescents.2 continuing standard therapy (steroids / ACTH/ Vigabatrin)
Most of these manifestations (except taste and smell for infantile spasms.8 Similarly children with DMD can
impairment) were associated with severe COVID-19 in continue steroids which may be converted to stress dose in
adults which are rare in children. While cerebrovascular case of acute illness based on the judgement of treating
events (both ischemic and hemorrhagic) have been physician. 9 Intravenous immunoglobulin (IVIg) and
associated with severe disease and lymphopenia in adults, azathioprine may also be initiated and continued with
there are no reports of cerebrovascular events in children. routine precautions and careful monitoring of lymphocyte
The striking absence of literature on cerebrovascular events counts in the case of azathioprine.10 However, the risk-
in children may probably be due to the presence of proactive benefit ratio should be carefully considered before
anti-thrombotic factors in young age and absence of rituximab initiation.10
comorbidities like atherosclerosis and hypertension.
Other rare associations of COVID-19 in adults include Children with disabilities and their families frequently
Guillain Barre syndrome, meningoencephalitis, acute require medical support as compared with typically
necrotizing encephalopathy and ataxia.7 These findings developing children. Also, their rehabilitation needs may
have not been reported in children to date except a solitary further be heightened with lockdowns due to restricted
case of suspected encephalitis in an adolescent described mobilization and closure of special schools and early
above.3 intervention centers. Continual provision of medical
services (including rehabilitation) by telemedicine is the
The basis of diagnosis in these cases was RT-PCR of need of the hour.
nasopharyngeal swab specimen for SARS-CoV-2 which
Conclusion
appears to be a useful investigation for confirmation of
COVID-19 even in children with neurological presentation. A high index of suspicion and characterization of
Considering the hazards of aerosol generation and low clinical features by the neurologists on the frontline are
yield, CSF examination may not be a practical key to diagnosis which should be aided by the provision of
investigation. appropriate PPE. For outpatient care and rehabilitation of
children with NDD, teleconsultation may be a beneficial
Considerations in children with
approach.
neurodevelopmental disorders (NDD)
Points to Remember
Severity of the COVID-19 infection represents a major
challenge to patients already afflicted with chronic • Neurological manifestations are reported in pediatric
and possibly acute neurological diseases and their COVID-19 albeit in lower frequency than that in
caregivers. Children with chronic neurodevelopmental adults.
disorders (NDD) are a vulnerable population in this regard • Symptoms range from mild ones like headache to
due to limited understanding of the mode of spread of full blown meningoencephalitis.
COVID-19, inevitable dependency on caregivers for
personal hygiene and care, and limited access to health- • Whether the SAR-CoV-2 virus is the etiologic or an
care facilities. Also, the NDDs are quite prevalent and incidental accompaniment is yet to be elucidated.
afflicted children often have multiple comorbidities such References
as spasticity, movement disorders, gastroesophageal reflux,
seizures, etc. which need to be looked after. 1. Wu Z, McGoogan JM. Characteristics of and Important
Lessons From the Coronavirus Disease 2019 (COVID-19)
Besides, children with specific neurological disorders may
Outbreak in China: Summary of a Report of 72314 Cases
require immunosuppressive therapy such as steroids which
From the Chinese Center for Disease Control and
may act as a double-edged sword. Therefore, policy-making Prevention. JAMA 2020; 323(13):1239.
and resource allocation should be consciously aimed at
2. Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al.
providing optimal care to children with NDDs. Neurologic Manifestations of Hospitalized Patients With
Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol
There is a rising concern about initiating and
[Internet]. 10th Apr, 2020 [cited 2020 Apr 22]; Available
continuing immunosuppressive therapies like from https://jamanetwork.com/journals/jamaneurology/
adrenocorticotrophic hormone (ACTH) or steroids in fullarticle/2764549.

33
Indian Journal of Practical Pediatrics 2020;22(2) : 146

3. McAbee GN, Brosgol Y, Pavlakis S, Agha R, Gaffoor M. hospitalized for COVID-19. Neurology 2020 Apr 28.
Encephalitis Associated with COVID-19 Infection in an DOI:https://doi.org/10.1212/WNL.0000000000009673.
11 Year-Old Child. Pediatr Neurol 2020 Apr; 8. Child neurology society statement for release_Management
S0887899420301430. of Infantile spasms (IS) during COVID-19 pandemic.
4. Dugue R, Cay-Martínez KC, Thakur K, Garcia JA, April 2020 [Internet]. [Last accessed on 15th May, 2020].
Chauhan LV, Williams SH, et al. Neurologic manifestations Available from: https://www.childneurologysociety.org/
in an infant with COVID-19. Neurology. 23rd Apr, 2020; docs/default-source/2020-cns-/cns-statement
10.1212/WNL.0000000000009653. -for-release_management-of-infantile-spasms-during
5. Chacón-Aguilar R, Osorio-Cámara JM, Sanjurjo- -the-covid-19-pandemic- (4-6-20).pdf? sfvrsn=
Jimenez I, González-González C, López-Carnero J, Pérez- 435065b8_2.
Moneo-Agapito B. COVID-19: Fever syndrome and 9. Veerapandiyan A, Wagner KR, Apkon S, McDonald CM,
neurological symptoms in a neonate. Anales de Pediatría Mathews KD, Parsons JA, et al. The care of patients with
(English Edition). 2020 Apr; S2341287920300661. Duchenne, Becker, and other muscular dystrophies in the
6. Nathan N, Prevost B, Corvol H. Atypical presentation of COVID 19 pandemic. Muscle Nerve 2020 May 5; mus.
COVID-19 in young infants. Lancet 2020; 26902.
395(10235):1481. 10. Manji H, Carr AS, Brownlee WJ, Lunn MP. Neurology in
7. Herman C, Mayer K, Sarwal A. Scoping review of the time of COVID-19. J Neurol Neurosurg Psychiatry
prevalence of neurologic comorbidities in patients 2020; 91(6):568-570.

CLIPPINGS

Ignaz Semmelweis : Father of hand hygiene.

Handwashing has been a central component of personal hygiene for many years. However, the link between
handwashing and health was first made by Ignaz Semmelweis, a Hungarian doctor working in Vienna General
Hospital, who is known as the father of hand hygiene. In 1846, he noticed that the maternal mortality in /
doctor-run maternity ward in his hospital were much more than the adjacent midwife-run maternity ward.
He investigated and noticed that doctors often visited the maternity ward directly after performing an
autopsy. Based on this observation, he developed a theory that those performing autopsies got ‘cadaverous
particles’ on their hands, which they carried from the autopsy room to maternity ward and this is responsible
for fatal puerperal fever. Midwives were not exposed to these particles.

As a result, Semmelweis imposed a new rule mandating handwashing with chlorine for doctors. The rates of
death in his maternity ward fell dramatically from 10 percent to 2 percent This was the first proof that
cleansing hands could prevent infection. However, the innovation was not popular with everyone. In 1861
he published his principal work - The Etiology, Concept, and Prophylaxis of Childbed Fever. Later he was
dismissed from the hospital for political reasons, harassed by the medical community and contemporaries.
Later abandoned by his wife, believing that he was losing his mind, and in 1865 he was committed to an
asylum. He died there of septicemia only 14 days later, possibly as a result of being beaten up by guards.
He died for the cause he promoted.

Only years after his death, Louis Pasteur developed the germ theory of disease, offering a theoretical
explanation for Semmelweis’s findings. After 150 years, it was the Semmelweis University (SU) in Budapest
that first adapted a digital tool to teach hand disinfection technique. Now washing hands with soap and
water is universally agreed to be the most effective method to prevent the spread of the new coronavirus,
SARS-CoV-2,

Global Handwashing Partnership. http:/globalhandwashing.org/abouthandwashing/historyof

handwashing/Accessed on 14th June 2020.

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Indian Journal of Practical Pediatrics 2020;22(2) : 147

COVID - 19

DIAGNOSIS OF COVID-19 IN CHILDREN since the onset of the pandemic, children are most likely
to get infected from household contacts. Hence, history of
*Tanu Singhal sick family members is important. In published reports from
Abstract: The world is facing an unprecedented crises China, a significant percentage of children with
with the advent and spread of COVID-19. Fortunately COVID-19 were infected from household contacts. 5
children are less affected. Diagnosis begins with identifying The common manifestations which merit evaluation for
the right suspect which in turn depends on local prevalence COVID-19 in the context of epidemiologic and contact
of infection and contact history. In high burden areas any history include:
acute illness with or without fever can be COVID-19. • Any acute illness with no other explainable cause
The gold standard for diagnosis is RT-PCR in respiratory
specimen. Correct collection and transport of specimen is • Fever with or without associated respiratory/
important. Since the sensitivity of RT-PCR is at best 70%, gastrointestinal manifestations
a negative test does not rule out the diagnosis. Sick children
• Runny nose, sore throat, cough, loss of sense of taste
may have lymphopenia and elevated CRP, D-dimer, ferritin,
or smell
CPK, LDH, IL-6. CT chest is more sensitive than CXR and
may be abnormal even in those who are asymptomatic or • Myalgia, fatigue
have mild symptoms. The role of serologic tests in children
at this time is limited to diagnosis of pediatric multi system • Abdominal pain, diarrhea and vomiting
inflammatory syndrome.
• Irritability, drowsiness, seizures, stroke
Keywords: SARS-CoV-2, COVID-19, Children, Diagnosis.
• Breathlessness, tachypnea, hypoxia
COVID-19 has been ravaging the world since the past
• Manifestations of pediatric multi system inflammatory
four months with devastating consequences.1 Globally
syndrome including fever, conjunctivitis, rash,
more than 6 million people have been affected and almost
hypotension
4,00,000 lives lost.2 Fortunately, disease in neonates, infants
and children has been mild with less morbidity and Asymptomatic household contacts of COVID-19
mortality.3 However, unusual manifestations such as the positive patients should be tested once between day 5 and
pediatric multi system inflammatory syndrome (PIMS) are 10 of exposure as per recent ICMR guidelines.6 Similarly
now being reported.4 It is possible that with the evolution newborns born to mothers who were COVID-19 positive
of the pandemic, there may be a change in the spectrum within 2 weeks of delivery or those who have been in
and severity of disease in children and recognition of new contact with COVID-19 infected family members should
manifestations. In this article we shall discuss the diagnosis be tested at birth and then before discharge.7
of COVID-19 in general, with focus on children.
Diagnosis
When to suspect?
The diagnosis of COVID-19 in the right clinical setting
The definition of ‘Supect COVID-19’ will vary with can be confirmed only by molecular tests as per current
the local prevalence and contact history. With widespread guidelines. Other laboratory tests and radiology offer
closure of schools and day care centres and lockdowns supportive evidence. The role of antibody test is limited.
Viral cultures are usually performed only for research
* Consultant-Pediatrics and Infectious Diseases, purposes. Genome sequencing is also a research tool to
Kokilaben Dhirubhai Ambani Hospital and determine viral virulence, aid in vaccine development and
Medical Research Centre, Mumbai. understanding epidemiologic characteristics of the virus
email: tanusinghal@yahoo.com such ascirculation of the virus/place of origin.8

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Indian Journal of Practical Pediatrics 2020;22(2) : 148

Molecular tests (Nucleic acid amplification protective equipment (PPE) including eye protection,
tests/ NAAT) 9 N 95 mask, gloves and gown while collecting the specimen.
The samples have to be collected by synthetic swabs and
Basis
immersed in viral transport medium and transported on
NAAT tests conducted on respiratory secretions are ice. Saliva is also being evaluated and found comparable
currently the gold standard for diagnosing COVID-19. in efficacy to other respiratory specimens and obviates the
The most common NAAT assays in commercial use are need for swab sticks and the transmission risks associated
the RT-PCR tests. These tests have two targets. The first during collection. 11 If the samples are not processed
screening gene is the generic coronavirus gene coding for immediately, they should be frozen at -20oC.
either the spike protein (S), nucleocapsid protein (N),
Sensitivity
envelope protein (E) or membrane protein (M). The second
target is the gene specific to COVID-19 which could be Sensitivity of the molecular methods is difficult to
the gene coding for RNA dependent RNA polymerase or assess since they themselves are the gold standard for
spike protein (S) or the open reading frame, ORF 1 or 2. diagnosis. The sensitivities reported in literature are based
Hence, the sensitivity of kits may vary depending on the on test positivity in clinically suspect cases with
target genes used. The common kits in use in India are epidemiologic, contact and radiologic corroboration.
Altona Real star CoV-2 real-time PCR kit, Thermo
TaqPATH COVID-19 and the indigenous Mylab The sensitivity of the molecular tests depends on many
PathoDirect COVID-19 kit. All these tests require first factors including the site of collection, method of
DNA extraction and then PCR. They need batching of collection/ transport and duration of illness prior to
samples, technical expertise and the testing time is 4-6 collection. A study from China which evaluated 1000 swabs
hours. Since most laboratories run only a few batches per from multiple sites reported the best sensitivity from lower
day, the turn around time may actually be 24-36 hours respiratory tract specimens (bronchoalveolar lavage 90%,
depending on when the sample is submitted. Cepheid the sputum 70%) followed by nasopharyngeal swabs
manufacturers of Xpert MTB/ Rif have developed a (50%) and lowest from nasal and oropharyngeal swabs
RT-PCR assay for SARS-CoV-2 called Xpert Xpress (20-30%). 12 The sensitivity is higher in the early phase of
SARS-CoV-2 which does not require separate DNA the illness and decrease as the illness progresses,
extraction and hence can deliver results within 2 hours after particularly after the first week. The tests are often negative
submission of the sample. It also does not need technical in children and adolescents with the Kawasaki disease like
expertise and can be run as an individual test and samples multisystem inflammatory syndrome.4
need not be batched. It is particularly useful when rapid
While there is scanty data about the sensitivity in
results are needed.
children, one study from China that evaluated more than
The tests are semi quantitative in nature wherein, the 2000 children with suspect COVID-19 disease reported
viral load can be estimated from the cycle threshold (Ct) virologic positivity only in 33% of the cases. 13 Children
i.e. the number of cycles that need to be run to amplify the with high clinical suspicion of the disease but initial
RNA. The usual cut off for most test kits is 40 (for the negative molecular tests should be treated as COVID-19.
Xpert Xpress kit it is 45). If the cycle threshold is above Tests can be repeated on a daily basis in suspect cases.
the cut off, test is negative. The lower the Ct, the higher is If lower respiratory samples are available, they should be
the viral load. The Ct values also tend to correlate with tested. However, doing bronchoscopies for getting access
infectivity. High Ct values are associated with non viable to lower respiratory specimens for diagnostic purposes is
virus and low risk of transmission. However these Ct values not recommended as these are invasive requiring technical
are assay dependent and have been variably reported as expertise, aerosol generating procedures and associated
>24/ >34 between different assays 10 with heightened risk of transmission to health care workers.
Collection of samples Specificity
The molecular test is performed on respiratory The RT-PCR tests are highly specific. However, since
secretions which can be collected from the upper they detect only RNA sequences of the virus, they can
respiratory (nasal swab, oropharyngeal swab, remain positive for weeks and months. Therefore in
nasopharyngeal swab) or lower respiratory (sputum, children who are asymptomatic and test positive on throat
endotracheal aspirate, bronchoalveolar lavage) tracts. swab (such as before elective surgeries) it cannot be
The person collecting the swab should wear proper personal inferred when they were infected and whether they are
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Indian Journal of Practical Pediatrics 2020;22(2) : 149

currently infectious or not. Therefore positive results should Hence, it is reasonable to say that these tests are
be interpreted with caution in patients who are primarily of value to assess the severity of COVID-19 and
asymptomatic and have no history of close contact with do not really aid the diagnosis of the disease.
COVID-19 patients. This is also true for children who have Poor prognostic markers in adults have been absolute
tested positive in the past and then are readmitted with lymphocyte count of < 1000, absolute neutrophil count:
some acute illness and test positive again. These were absolute lymphocyte count of > 3.5, elevation of CRP
earlier attributed to reinfections but now it is well beyond 100 mg/ L, increase in D-dimer to more than
established that COVID-19 produces at least short term 6 times normal and levels of IL-6 beyond 7-10 times
immunity against the virus. 14 Hence, these children who normal. 19
retest positive after recovery should not be managed/
isolated as COVID-19. The pediatric multi system inflammatory syndrome
is associated with marked rise in inflammatory parameters.
Repetition of molecular tests These children have usually an elevated white cell count
As discussed earlier, molecular tests can remain with neutrophilia and lymphopenia, but normal/ low
positive for a long time after infection, even weeks and platelet counts.4 The latter is unlike Kawasaki disease
months. Earlier, it was assumed that the patient is infectious where platelet counts increase progressively. These children
as long as SARS-CoV-2 RNA is detectable in the upper have high erythrocyte sedimentation rate and high CRP
respiratory tract and deisolation required demonstration levels. There is mild derangement of the liver enzymes.
of two negative swabs 24 hours apart.15 However, this These children also show other laboratory abnormalities
approach resulted in multiple tests and prolonged hospital like raised triglycerides, fibrinogen, ferritin and D-dimer
stay and was very resource intensive. 16 Meanwhile, it was and elevated troponin I. Hyponatremia was also a common
reported that viable virus was seldom cultured after feature. Some of these children also had elevated levels of
7-10 days of the illness if the patient had recovered.17 IL-6. The ECHO in some showed evidence of coronary
Hence, now as per new national guidelines, patients with artery aneurysms and reduced ejection fraction.
COVID-19 can be deisolated once 10 days have elapsed
from the time of symptom onset and three days since Radiology 22
clinical recovery, whichever is longer. 18 However, there is Chest radiology plays an important diagnostic role in
little information about infectivity in patients with severe COVID-19 disease. However, radiology in COVID-19
and protracted illness and current guidelines recommend presents logistic challenges due to transmission risks to
demonstrating one negative swab prior to discharge in health care workers and radiation risks to the patients.
severe cases. 18
Hematologic and biochemical parameters The CxR’s are usually normal in mild/ early disease.
In those with severe disease, it is abnormal with bilateral
The changes in hematologic and biochemical infiltrates and sometimes complete white out of the lungs.
parameters in COVID-19 have been extensively studied.
These studies have been mainly in hospitalized adults and
abnormalities depend on the severity of disease.19 20
The white blood cell count is usually normal or low with
lymphopenia and elevated absolute neutrophil: lymphocyte
ratio. The platelet counts are normal or mildly decreased.
There is elevation of C reactive protein but procalcitonin
is normal. In patients with severe disease there is elevation
of creatine phosphokinase (CPK), lactate dehydrogenase
(LDH), D-dimer, ferritin and interleukin-6 (IL-6).
There may be mild derangement of liver enzymes, elevation
of creatinine and prolongation of prothrombin time/
activated partial thromboplastin time. There may be
elevation of troponin in some patients indicating
myocardial involvement. In children, there is less
derangement of the hematologic and biochemical
parameters discussed above.21 This may also be related to Fig.1. CT scan of a mildly symptomatic child
the fact that the disease is less severe in children. showing a peripheral ground glass opacity
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Indian Journal of Practical Pediatrics 2020;22(2) : 150

However, the immune response is not uniform in all

individuals and severe infections are associated with
stronger immune responses. People with mild disease or
those who are asymptomatic may not develop an immune
response at all. This is possibly attributed to the innate
immune response wiping out the virus before the adaptive
immune response can kick in.

Detection of immune response

It is expected that IgM detection should be more useful

since these antibodies appear early; however IgM
antibodies cross react with other circulating coronaviruses.
On the other hand, IgG response though a little delayed
persists for a long time and is more specific. Detection of
Fig.2. CT image in a child with severe virus neutralizing antibodies by special assays is the best
COVID-19 disease approach since these antibodies correlate with future
protection. However, viral neutralizing assays are only
CT scans of the lungs are infinitely more sensitive possible in research laboratories. IgA antibodies are also
than CxR. Some series reported abnormal CT scans in 20% reliable but are not included in most commercial kits.
of children who were clinically asymptomatic. In those
who had symptoms, chest CTs were abnormal 2/3rd of the Several antibody detection kits that are based on
time. 22 Disease could be bilateral/ unilateral with principle of enzyme-linked immunosorbent/
predominant involvement of lower lobes than the upper Chemiluminescence immunoassay (ELISA/ CLIA) have
lobes and lesions more peripheral than central. The most been developed that detect both IgM and IgG antibodies
common radiologic finding is that of ground glass opacity or combined antibodies or only IgG antibodies. They differ
(Fig.1). Other findings include consolidations, crazy paving in sensitivity and specificity and in-house validation of kits
pattern and the halo and reverse halo signs. Findings can is strongly recommended. Rapid serologic tests based on
be severe in patients with clinical evidence of pneumonia lateral flow assays have been developed. These can give
and hypoxia (Fig.2). Pleural effusions were rare. the results within 10-15 minutes but have not been validated
As compared to adults, CT findings are less common and sufficiently and are possibly less sensitive than ELISA.
less severe in children which basically correlates with the
Clinical application of serologic tests
fact that disease is less severe in children. Symptomatic
adults had abnormal CT, 90% of the times unlike children, While serologic tests hold great promise, they have
where the CT was abnormal 60% of the time. Also, adults not been commonly used in the clinical setting. Indications
were more likely to have bilateral involvement unlike of these tests include:
children where almost half the times there was unilateral
involvement. Some studies in adults reported superior • Diagnosis of COVID-19 infection in those patients
sensitivity of CT scan as compared to RT-PCR in diagnosis who have COVID-19 like illness and who test negative
of COVID-19.23 This was however not observed in children. by RT-PCR methods. These tests could thus prove
useful in those who present with prolonged symptoms
Point of care lung ultrasound is also emerging as a when the viral shedding is less. This is especially the
useful diagnostic investigation in COVID-19.24 Since the case in the multi system inflammatory syndrome where
lesions are peripheral in COVID-19 they are readily picked RT-PCR is negative but antibody tests are positive.
up by lung USG and termed as straight beam sign.
• To estimate the prevalence of infection in population
Serologic diagnosis 9,25,26 and health care workers. This would indirectly help
in assessment of herd immunity and effectiveness of
Kinetics of immune response
infection control measures in hospitals. Recent studies
COVID-19 is associated with a gradual development also indicate that infection with COVID-19 leads to
of an immune response. IgM antibodies appear 1-2 weeks short term protection against reinfections. 14 If more
after infection almost followed immediately by IgA evidence accumulates that presence of antibodies
antibodies and then IgG antibodies between 2-3 weeks. equates with protection against future infection,
38
Indian Journal of Practical Pediatrics 2020;22(2) : 151

deployment of such people in front line work would than adults? [published online ahead of print, 14th May,
also be possible. 27 The main drawback of this approach 2020]. Indian J Pediatr 2020; 1 10. doi:10.1007/s12098-
is that mildly symptomatic people or those who have 020-03322-y.
been asymptomatically infected may not mount a 4. Verdoni L, Mazza A, Gervasoni A, Martelli L, Ruggeri M,
detectable immune response and thus test falsely Ciuffreda M, et al. An outbreak of severe Kawasaki-like
negative. Hence, absence of antibodies does not disease at the Italian epicentre of the SARS-CoV-2
epidemic: an observational cohort study [published online
indicate absence of previous infection.
ahead of print, 2020 May 13]. Lancet 2020;10.1016/
• To estimate the level of protection given by S0140-6736(20)31103-X. doi:10.1016/S01406736
convalescent plasma before transfusion to patients (20)31103-X.
with COVID-19. Ideally the titre of neutralizing 5. Zhu L, Wang J, Huang R, Liu L, Zhao H, Wu C, et al.
antibodies should be determined but these assays are Clinical characteristics of a case series of children with
not always universally available. coronavirus disease 2019. Pediatr Pulmonol 2020;
55(6):1430-1432. doi:10.1002/ppul.24767.
Conclusion
6. Indian Council of Medical Research. Revised testing
COVID-19 is challenging our lives and resources like strategy for India. Available at https://www.icmr.gov.in/pdf/
never before. Currently, the most common cause of fever covid/strategy/Testing_Strategy_v5_18052020.pdf.
Accessed on 30th May, 2020.
with or without any other focus is COVID-19. While we
can draw comfort from the fact that children tend to have 7. Chawla D, Chirla DI, Dalwai S, Deorari AK, Ganatra A,
Gandhi A, et al. Perinatal-Neonatal Management of
milder disease as compared to adults, diagnosis of
COVID-19 Infection - Guidelines of the Federation of
COVID-19 in them is equally important. The RT-PCR in Obstetric and Gynecological Societies of India (FOGSI),
appropriately collected nasopharyngeal swab is the National Neonatology Forum of India (NNF), and Indian
diagnostic method of choice. False negative results can be Academy of Pediatrics (IAP). Indian Pediatr 2020;
seen in 30-50% of the cases. Hematologic and biochemical S097475591600154.
markers and radiology play a supporting role and help in 8. Maurano MT, Ramaswami S, Westby G, Zappile P,
assessment of disease severity. The role of antibody tests Dimartino D, Shen G, et al. Sequencing identifies multiple,
is yet to be elucidated. early introductions of SARS-CoV2 to New York City
Region. Preprint. medRxiv. 2020; 2020.04.15.20064931.
Points to Remember doi: https://doi.org/10.1101/2020.04.15.20064931.
• The gold standard test for diagnosis of COVID-19 at 9. Sethuraman N, Jeremiah SS, Ryo A. Interpreting
this time is RT-PCR in respiratory tract specimens. Diagnostic Tests for SARS-CoV-2 [published online ahead
of print, 6th May, 2020]. JAMA 2020;10.1001/jama.
• The sample has to be collected and transported 2020.8259. doi:10.1001/jama.2020.8259.
properly. 10. Binnicker MJ. Can the SARS-CoV-2 PCR cycle threshold
value and time from symptom onset to testing predict
• A negative RT-PCR does not rule out the diagnosis infectivity? [published online ahead of print, 2020 Jun 6].
of COVID-19. Clin Infect Dis 2020; ciaa735. doi:10.1093/cid/ciaa735.
• Presence of lymphopenia, high CRP/ ferritin/ 11. Ceron JJ, Lamy E, Martinez-Subiela S, Lopez-Jornet P,
D-dimer/ CPK/ LDH may indicate severe disease. Capela e Silva F, Eckersall PD, et al. Use of Saliva for
Diagnosis and Monitoring the SARS-CoV-2: A General
• CT may be useful in the right clinical setting for quick Perspective. J Clin Med 2020; 9(5):E1491. Published 2020
triaging of suspect cases and evaluation of RT-PCR May 15. doi:10.3390/jcm9051491.
negative cases. 12. Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, et al. Detection
of SARS-CoV-2 in Different Types of Clinical Specimens.
References
Jama 2020; 323(18):1843-1844.
1. Singhal T. A Review of Coronavirus Disease-2019 13. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al.
(COVID-19). Indian J Pediatr 2020; 87(4):281286. Epidemiology of COVID-19 among children in China.
doi:10.1007/s12098-020-03263-6. Pediatrics 2020; 145(6) e20200702. https://doi.org/
2. COVID-19 coronavirus pandemic. Available at https:// 10.1542/peds.2020-0702.
www.worldometers.info/coronavirus/. Accessed on 14. Kang H, Wang Y, Tong Z, Liu X. Re-test Positive for
6th June, 2020. SARS-CoV-2 RNA of “Recovered” Patients with COVID-
3. Dhochak N, Singhal T, Kabra SK, Lodha R. 19: Persistence, Sampling issues, or Re-infection?. J Med
Pathophysiology of COVID-19: Why children fare better Virol 2020;10.1002/jmv.26114. doi:10.1002/jmv.26114.
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15. Government of India Ministry of Health & Family Welfare 22. Steinberger S, Lin B, Bernheim A, Chung M, Gao Y,
Directorate General of Health Services (EMR Division). Xie Z, et al. CT Features of Coronavirus Disease
Revised guidelines on clinical management of (COVID-19) in 30 Pediatric Patients. Am J Roentgenol
COVID - 19. Available at https://www.mohfw.gov.in/pdf/ 2020; 1-9.
RevisedNationalClinicalManagementGuideline for
23. Huang P, Liu T, Huang L, Liu H, Lei M, Xu W, et al.
COVID-1931032020.pdf. Accessed on 3rd April, 2020.
Use of chest CT in combination with negative RT-PCR
16. Shah S, Singhal T, Davar N, Thakkar P. Initial Observations assay for the 2019 novel coronavirus but high clinical
with Molecular Testing for COVID-19 in a Private Hospital suspicion. Radiology 2020; 295(1):22-23.
in Mumbai, India [published online ahead of print, 2020
May 6]. Indian J Pediatr 2020;1. doi:10.1007/s12098-020- 24. Denina M, Scolfaro C, Silvestro E, Pruccoli G,
03325-9. Mignone F, Zoppo M, et al. Lung ultrasound in children
with COVID-19. Pediatrics;e20201157. Available from:
17. Wölfel R, Corman VM, Guggemos W, Seilmaier M,
http://pediatrics.aappublications.org/lookup/doi/10.1542/
Zange S, Müller MA, e al. Virological assessment of
peds.2020-1157.
hospitalized patients with COVID-2019. Nature 2020;
581(7809):465-469. 25. Bohn MK, Lippi G, Horvath A, et al. Molecular,
18. ICMR. Revised discharge policy. https://www.mohfw.gov. serological, and biochemical diagnosis and monitoring of
in/pdf/FAQsonRevisedDischarge Policy. pdf. Accessed on COVID-19: IFCC taskforce evaluation of the latest
May 30,2020. evidence. Clin Chem Lab Med. 2020;/j/cclm.ahead-of-
print/cclm-2020-0722/cclm-2020-0722.xml. doi:10.1515/
19. Lippi G, Plebani M. Laboratory abnormalities in patients
cclm-2020-0722.
with COVID-2019 infection. Clin Chem Lab Med. 2020;/
j/cclm.ahead-of-print/cclm-2020-0198/cclm-2020- 26. Younes N, Al-Sadeq DW, AL-Jighefee H, Younes S,
0198.xml. Al-Jamal O, Daas HI, Yassine HM, Nasrallah GK.
20. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Challenges in laboratory diagnosis of the novel coronavirus
Clinical characteristics of coronavirus disease 2019 in SARS-CoV-2. Viruses. 2020; 12(6):582.
China. N Engl J med 2020; 382(18):1708-1720. 27. Phelan AL. COVID-19 immunity passports and
21. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. vaccination certificates: scientific, equitable, and legal
SARS-CoV-2 infection in children. N Engl J Med 2020; challenges. Lancet 2020; 395(10237):15951598.
382(17):1663-1665. doi:10.1016/S0140-6736(20)31034-1035.

CLIPPINGS

A new therapeutic strategy in severe COVID-19.

Patients with severe COVID-19 have a hyperinflammatory immune response suggestive of macrophage activation.
Bruton tyrosinase kinase (BTK) regulates macrophage signaling and activation.
Aclabrutinib, a selective BTK inhibitor, was administered off- label to 19 patients hospitalized with severe
COVID-19 (11 on supplemental oxygen; 8 on mechanical ventilation), 18 of whom had increasing oxygen
requirements at baseline. Over a 10-14 day treatment course, acalabrutinib improved oxygenation in a majority
of patients, often within 1-3 days, and had no discernible toxicity. Measures of inflammation-C-reactive protein
and IL-6-normalized quickly in most patients, as did lymphopenia, in correlation with improved oxygenation.
At the end of acalabrutinib treatment, 8/11(72.7%) patients in the supplemental oxygen cohort had been discharged
on room air and 4/8 (50%) patients in the mechanical ventilation cohort had been successfully extubated, with
2/8(25%) discharged on room air. Ex vivo analysis revealed significantly elevated BTK activity, as evidenced
by autophosphorylation and increased IL-6 production in blood monocytes from patients with severe
COVID-19 compared with blood monocytes from healthy volunteers.
These results suggest that targeting excessive host inflammation with a BTK inhibitor is a therapeutic strategy
in severe COVID-19 and has led to a confirmatory international prospective randomized controlled clinical
trial.
Roschewski M, Lionakis MS, Sharman JP, Roswarski J, Goy A, Monticelli MA, Inhibition of Bruton
tyrosine kinase in patients with severe COVID-19. Science Immunology 05 Jun 2020:Vol. 5, Issue 48, eabd0110
DOI: 10.1126/sciimmunol.abd0110.
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Indian Journal of Practical Pediatrics 2020;22(2) : 153

COVID - 19

MANAGEMENT OF COVID-19 IN These pieces of information need to be interpreted in

COMMUNITY AND NON-ICU SETTINGS concurrence with the epidemiological pattern in the specific
geographical area.
*Sasidaran K
**Sheeja Sugunan Clinical features of COVID-19

Abstract: Coronavirus disease 2019 (COVID-19) caused The incubation period ranges from 2 - 14 days.
by SARS-COV-2 is rarer in children compared to adults. Asymptomatic infections have been reported in 4% of
Most countries have reported an incidence of 1- 2% . children. Illness often starts with mild symptoms like fever,
Whether this reflects ‘lower susceptibility’ or ‘higher dry cough and sore throat. Fever is seen in about 41% of
proportion of asymptomatic infection in this age group’ is pediatric patients. 10% of patients may present with GI
not really known. Nevertheless, severe manifestations and symptoms like diarrhea and vomiting, while rhinorrhea is
deaths are increasingly reported in children. They can act relatively rare, being seen in around 7.6% of patients.1
as a source of infection for adults and health care workers, Patients may also complain of myalgia, headache and
as they cannot follow cough etiquettes as efficiently as fatigue. Clinical syndromes associated with COVID-19
adults. Here, we provide a brief overview of pre-ICU infection include mild, uncomplicated illness with fever,
management perspectives of COVID-19 disease in sore throat, malaise, cough, diarrhea or vomiting, mild
children. pneumonia, severe pneumonia, ARDS, sepsis and shock
with multi-organ involvement currently labelled as
Keywords: COVID-19, Children, Management. inflammatory multisystem syndrome, temporally
associated with SARS-CoV-2.
When to suspect COVID-19 in children
Clinical progression and heterogeneity in
The reported incidence of COVID-19 in most clinical presentation
countries is 1- 2%.1 All symptomatic (fever /cough/
shortness of breath) children who have undertaken Around 81% of COVID-19 infections in adults are
international travel in the last 14 days, symptomatic mild; 14% have moderate to severe symptoms, with
contacts of laboratory-confirmed cases, children 5% of patients having critical illness requiring ICU
hospitalized with severe acute respiratory illness (SARI) admission. 3 Studies in children have reported fewer severe
(fever and cough with onset within last 10 days and requires (5% vs14%) and critical cases (0.6%Vs 5%) (compared to
hospitalisation as defined byWHO) and asymptomatic adults.2 Hospitalization is more common in children under
direct and high-risk contacts of a confirmed case need to one year of age and in those with comorbidities. The clinical
be considered as COVID-19 suspect. One needs to course may be hyper-acute with rapid onset of fever and
remember that indications to clinically suspect breathlessness or moderate with slower progression of
COVID-19 was derived predominantly from the adult symptoms and later recovery or biphasic with late
database. The symptomatology is getting broadened over progressive worsening and multi-organ involvement
time as there are multiple documentations of heterogeneous including ARDS, sepsis and septic shock.4
presentation including multisystem inflammatory Multisystem inflammatory syndrome in children
syndrome, acute heart failure, acute abdomen, etc. (MIS-C) or Pediatric Multisystem Inflammatory Syndrome
* Pediatric Intensivist and Head, temporally associated with SARS-CoV-2 infection,
Advanced Pediatric Critical Care Centre, (PIMS-TS): This may occur weeks after a patient is infected
Mehta Multispecialty Hospital India Pvt. Ltd., Chennai. with COVID-19. Some patients may have been infected
** Associate Professor and Pediatric Intensivist, asymptomatically also. Patients present with high persistent
SAT Government Medical College, fever with multi-organ involvement like cardiac,
Thiruvanthapuram, Kerala. gastrointestinal, renal, hematologic, dermatologic or
email : sasidarpgi@gmail.com neurologic with elevated inflammatory markers.5
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Indian Journal of Practical Pediatrics 2020;22(2) : 154

Management of children with COVID-19 Box.1 Triage questions

Community management 1. Has someone in your close family returned from a
All children suspected of having COVID-19 exposure foreign country? Yes/No
or infection with mild symptoms should be advised 2. Is the patient under home quarantine as advised by
quarantine in COVID-19 isolation centres, if available or the local health authority? Yes/No
they may be advised home quarantine.
3. Have you or someone in your family come in close
Home quarantine : Patients should preferably stay in well contact with a confirmed COVID-19 patient in the
ventilated single rooms with attached bathrooms. If another last 14 days?Yes/No
person other than care taker of a small child needs to share
4. Do you have fever? Yes/No
the room, he should maintain a distance of one metre at all
times. He/she should stay away from older adults, pregnant 5. Do you have cough /sore throat? Yes/No
ladies, other children and patients with comorbidities. 6. Do you feel shortness of breath? Yes/No
They should practice strict personal hygiene, including
hand hygiene and wearing of masks. They should not share Clinical categorisation for planning therapy
utensils or clothes with other members of the family. Masks
All children with suspected COVID-19 infection
used by patients /close contacts during home care should
should be categorized into three categories.
be disinfected using ordinary bleach solution (5%) or
sodium hypochlorite solution (1%) and then disposed of Category A patients (mildly symptomatic patients)
either by burning or deep burial.6
These patients can be sent home or to COVID-19 care
Family members cleaning the room or handling soiled centres with supportive care. Avoid using non-steroidal
linen should wear disposable gloves and wash hands with anti-inflammatory drugs other than paracetamol. Advice
soap and water after removing gloves. Clean frequently regarding prevention and treatment of dehydration with
touched surfaces with 1% sodium hypochlorite solution ORS and appropriate use of other home available fluids in
and toilet seats with household bleach or phenolic case of diarrhea and vomiting. Patients should be clearly
disinfectants. Wash linen separately with detergent and dry. instructed about danger signs and the occurrence of any
Patients should seek medical advice if any COVID-19 new symptom or worsening of existing symptom warrants
infection symptoms appear including fever, cough, review. These patients should be reviewed every 24-48
diarrhoea, vomiting or breathlessness and all close contacts hours. Telemedicine facilities may be used for reviewing
in such a situation should be home quarantined (for 14 mildly symptomatic patients. Patients may be offered zinc
days). This may be followed up for an additional 14 days 2mg/kg/day, (maximum 20 mg) especially in the presence
or till the report of such case turns out negative on lab of diarrhea. All category A patients with a history of contact
testing. Asymptomatic direct and high-risk contacts of a with a confirmed case of COVID 19 should be tested for
confirmed case should be tested once between day 5 and COVID 19 with a nasopharyngeal swab.
day 14 after contact.
Hospital management Box.2 Clinical categories of COVID-19
Triage Category A
Hospitals should preferably establish a 3 tier triage Mild sore throat, fever, cough, rhinorrhea, diarrhea,
system. History of ‘international travel’ or ‘travel to hotspot vomiting.
areas in the last 14 days’ or ‘contact with suspected or
Category B
confirmed cases’ should be elicited at the point of the first
contact (out-patient counter or registration desk) and all Fever, severe sore throat, increasing cough. Category A
those with positive history should be directed to the symptoms in children with chronic heart, kidney, lung,
COVID-19 isolation area. All patients coming to the neurological or liver disease and children on long term
emergency or OPD should also be similarly triaged at the steroids, congenital or acquired immunosuppression.
entry point for respiratory symptoms and triple-layer Category C
surgical mask offered to patient and caretaker of all
suspected cases and directed to the designated COVID-19 Altered sensorium, respiratory distress, SpO2 < 94%,
isolation areas. In the COVID-19 isolation areas, the patient breathlessness, cyanosis, inability to feed, seizures,
should be triaged for the severity of the infection (Box 1). hypotension.
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Indian Journal of Practical Pediatrics 2020;22(2) : 155

Category B patients (moderate symptoms/ patient with • Presence of danger signs like inability to feed, altered
comorbidities) sensorium, seizure etc. without evidence of shock or
other organ involvement (these children may need
Admission: These patients may be preferably admitted in
transfer to PICU early for close monitoring if
isolation wards and nasopharyngeal swabs sent for
symptoms persist).
confirmation of disease. Children with comorbidities also
should be admitted in isolation wards. If the health care Admission in PICU
system is overburdened, those without comorbidities and • Moderate to severe ARDS ( PaO2/FiO2 (P/F) ratio less
danger signs can be admitted at COVID-19 care centres or than 200 / oxygenation index (OI) < 8 / Oxygen
advised to self-quarantine at home with follow up and low saturation index as measured by FiO2 x mean airway
threshold for admission in case of worsening of symptoms. pressure)/SpO2 values (OSI) < 7.5 while on CPAP of
Treatment: They may be started on oseltamivir 3mg/kg/ minimum 5 cm
dose BD if they fulfil the criteria for treatment of Influenza • SpO2 < 94% with increased work of breathing (> 2
like illness(ILI). WHO clinical case definition “An acute site retraction/ paradoxical breathing / see saw
respiratory illness with a measured temperature of > 38°C breathing / head bobbing etc.)
and cough, with onset within the past 10 days”. Antibiotics
as per clinician’s discretion to cover community-acquired • Suspecting atypical presentation of COVID, i.e.,
pneumonia including atypical pneumonia may be offered. Kawasaki disease (KD) like illness, multisystem
Once swab report is available and the diagnosis confirmed, inflammatory disorder etc.,
oseltamivir might be stopped and the patient started on • Shock
hydroxychloroquine 6.5mg/kg/dose BD on day one
followed by 3.25mg/kg/dose BD for four more days along • Multi-organ dysfunction
with zinc 2mg/kg/day.7 • Need for mechanical ventilation
Category C patients (severe and critical disease) • Transfer from ward or HDU for close monitoring /
mechanical ventilation
Category C patients require admission and treatment in
high dependency units or ICU’s according to severity of Management of admitted patients
illness. General measures
Admission in ward • Symptomatic treatment: Avoid giving NSAIDs other
than paracetamol for fever. Provide oral
• Presence of tachypnea (respiratory rate: <2 months
bronchodilators or MDI with spacer and mask for
>60/ minute; 2-11 months >50/minute; 1-5 years >40/
children with wheeze.
minute) without lower chest indrawing or danger signs
like lethargy, altered sensorium, inability to feed, • Antibiotics and antivirals may be given as per
convulsion, etc. clinicians discretion to cover community-acquired
pneumonia, including atypical infections and
• Children with high risk for severe disease with mild
influenza.
symptoms: children with congenital or acquired heart
disease, chronic lung, liver, kidney or neurological • Ensure euvolemia and advice adequate fluid and feed
disease, children on immunosuppressive drugs , intake.
congenital or acquired immunodeficiency Monitoring
• SpO2 90 - 94% without retractions and danger signs. • Vital signs - HR, RR, SpO2, BP
Admission in high dependency unit (HDU) • Work of breathing (retractions, use of accessory
• SpO2 less than 94% with <2 site retractions muscles, grunting, head bobbing, air hunger, large tidal
volume breaths)
• Children with comorbidities with a saturation of less
than 94% or tachypnea. • Oxygen requirement
• SpO2 < 90% without increased work of breathing. Laboratory investigations
• Children with tachypnea with lower chest in drawing/ Routine investigations: CBC with differential count
grunt. and ESR, RFT, LFT, coagulation profile, urine routine and
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Indian Journal of Practical Pediatrics 2020;22(2) : 156

send these in all admitted patients. Unlike adult patients COVID-19 pneumonitis : Hypoxia in COVID is
with COVID-19, there have been no consistent leukocyte multifactorial. Two basic types of lung phenotypes have
abnormalities reported in pediatric patients. Only 3.5% of been described: the L type and H type lung. These two
pediatric cases showed lymphopenia.1 Chest X-ray may phenotypes are not mutually exclusive; they may indicate
show patchy infiltrates consistent with viral pneumonia lung in different stages of evolution of the disease.
and chest CT scans may show nodular ground-glass Increased work of breathing contributes to lung damage
opacities. by increasing patient self-inflicted lung injury
(P- SILI) and is responsible for the transition from L Type
Biomarkers in sick children : CRP, LDH, D-dimer,
to H Type (Table I).8
CPK, ferritin, troponin I, elevated transaminases ,
prothrombin time, NT-ProBNP, BUN, creatinine. Send Oxygen therapy in COVID-19 infection
these in patients with severe or critical disease admitted in
HDU or PICU and those with worsening respiratory status. All areas where patients with SARI are cared for
should be equipped with pulse oximeters, functioning
Complications oxygen systems and disposable, single-use, oxygen-
COVID-19 infection primarily causes upper delivering interfaces (nasal cannula, simple face mask,
respiratory infection followed by pneumonitis of varying non- rebreathing mask).
severity. Some patients progress to develop • Give supplemental oxygen therapy immediately to
hyperinflammatory syndrome due to cytokine storm patients with SARI and respiratory distress,
clinically presenting with features of KD, cytokine release hypoxemia, or shock.
syndrome or infection associated HLH often leading to
multi-organ failure. Pointers towards hyperinflammatory • Target SpO2 > 94% during resuscitation and > 90%
syndrome include - for patients on oxygen therapy and those recovering
from pneumonia without respiratory distress.6
1. Persistent high fever or reappearance of fever.
• Nasal prongs or cannula are preferred in children as it
2. Rising CRP especially more than 100- 200 mg/L may be better tolerated. Offer a surgical mask or hood
3. Doubling of ferritin in 24 hours or very high ferritin covered by a surgical mask to decrease the risk of
levels (> 2000 - 10,000mcg/L) aerosolization and droplet spread.
4. Falling counts • If on prongs and SpO2 less than 90% with minimal
respiratory distress, options include
5. Rising or falling ESR
a) Face mask at flow > 5LPM (FiO2 40 - 60%)
6. Rising CPK, LDH
b) Oxygen hood at flow > 5 LPM (FiO2 30-90%)
7. New-onset shock especially with elevated trop I ( also
rule out Kawasaki disease with shock syndrome) c) Venturi mask (28-60% FiO2)

Table I. L type and H type lung characteristics

L type lung characteristics H type lung characteristics (typical ARDS lung)
• Good lung compliance • High elastance
• Low elastance • Low compliance
• Low ventilation-perfusion ratio due to abolition of • Wet lung
hypoxic vasoconstriction or pulmonary
thrombophlebitis leading to pulmonary thrombosis
• Low lung recruitability as the amount of non-aerated • High right to left shunt
lung less
• Relatively dry lung • Higher lung recruitability as the amount of non-aerated
lung is higher due to damage to the alveolar basement
membrane and loss of surfactant.
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Indian Journal of Practical Pediatrics 2020;22(2) : 157

d) Non-rebreathing mask at flow 10-15 LPM • Hydroxychloroquine / Chloroquine

(FiO2 80-90%).
• Lopinavir / Ritonavir
• If the flow of 15 LPM oxygen achieves saturation of
• Remedesivir
> 95%, it indicates the shunt fraction is mild. Failure
to accomplish this indicates a moderate-severe shunt • Nitazoxanide
fraction. These children should be closely monitored • Ivermectin
for deterioration and respiratory support should be
escalated as per need. Hydroxychloroquine : 6.5mg /kg /dose (Max 400 mg) PO
BD day 1 followed by 3.25mg per kg PO BD (max 200mg/
• Heated humidified high flow nasal cannula (HFNC)
dose) for 4 days. Usual treatment is for 5 days, but in select
may be used preferably over CPAD/BIPAP if the target
patients with extended ventilation or profound
saturation is not achieved with above oxygen delivery
immunosuppression, duration may be extended to 10 days.
devices. It should be used only in patients with
Retinopathy, rash, nausea, glucose fluctuations and
hypoxemic respiratory failure. It increases the risk of
diarrhoea include adverse events associated with HCQ
aerosolization, but the risk is less than that for other
therapy. GI symptoms can be mitigated by taking HCQ
NIV.
with food. Avoid taking hydroxychloroquine with antacids
• Switch on the machine only after fixing the nasal and separate administration by at least 4 hours.
cannula.
Contraindications: QT prolongation > 500 ms, porphyria,
• Start at 0.5 - 1litre per kg per minute and increase up
myasthenia gravis, retinal pathology, epilepsy. If baseline
to 2 litre/kg/minute if needed.
QT prolongation is present, take frequent ECG.
• Use minimal flow that makes the baby comfortable.
Chloroquine: 10 mg /kg chloroquine sulphate base stat
• Target SpO2 90 - 94%
followed by 5 mg per kg 12 hours later and then
• Monitor HR, RR, SpO2 and work of breathing. Monitor 5 mg/kg/ dose BD for four more days. Adult dose:
closely, if no response in 1- 2 hours will need escalation Chloroquine sulphate base 600mg stat followed by 300
of support. mg 12 hours later followed by 300mg BD for four days.
NIV CPAP: It may be offered only in selected patients
Lopinavir / Ritonavir
with hypoxemic respiratory failure. The failure rate with
NIV is very high, especially in de-novo respiratory failure, This may be considered on a case to case basis in
so these patients need close monitoring. severe disease (SpO 2 <94% in room air or requiring
supplemental oxygen, mechanical ventilation or ECMO)
• Use of conventional ventilators for NIV with non-
not responding to chloroquine after written consent and
vented oronasal masks/helmets preferable.
medical board concurrence and dose is given in Box 3.
• Avoid using dedicated NIV with single limb and vented
masks as the risk of aerosolization is very high. Box.3 Dose of Lopinavir/Ritonavir
• Connect a bacterial/viral filter at exhalation port • 14 days to 6 months : 16mg/kg/dose PO BID (based
on lopinavir component)
• Use the lowest possible PEEP to achieve targets.
• < 15kg : 12 mg/kg/dose PO BID (based on lopinavir
• Monitor closely for deterioration and intubate if the component)
patient deteriorates or there is no improvement in 1
hour or delivered tidal volume is more than 9.5ml/kg • 15-25 kg: 200 mg/50 mg PO BID
with increased work of breathing as P- SILI may • 26-35 kg: 300 mg/75 mg PO BID
damage the lung further.
• >35 kg: 400 mg/100 mg PO BID
• Placing of the aerosol box with ports covered by the
• Adult dose : 400/100 PO BID
surgical mask may decrease the risk of aerosolization.
Specific therapy Duration of treatment : 14 days or 7 days after becoming
asymptomatic.
No specific antiviral therapy is proven to be effective
as per currently available literature. Drugs being used in Adverse events: Hepatotoxicity, pancreatitis, diabetes, QT
clinical trial settings include prolongation, lipid elevations.
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Indian Journal of Practical Pediatrics 2020;22(2) : 158

Remedesivir Patient placement

Not currently freely available in India. EUA • If single rooms are available, admit patients in a single
(emergency use authorisation) has been granted by FDA room.
for use in children and adults with severe disease.
• If single rooms are not available, patients with the same
Dose : 5mg/kg IV (max. 200mg) loading dose over etiological diagnosis can be grouped. If the etiological
30 - 120 minutes on day 1 followed by 2.5mg/kg diagnosis is not confirmed, patients with a similar
(max.100mg) IV OD on days 2- 4. clinical diagnosis and epidemiological risk factors can
be grouped with spatial separation of 1 meter between
Duration of treatment: Usual duration 5 days. If no clinical beds.6
improvement, duration may be extended to total 10 days.
• Isolation ward should have separate entry and exit and
Infection prevention and control should not be located with post-surgical wards /dialysis
perspectives in COVID-19 scenario units/SNCU labour rooms.
Infection prevention and control (IPC) measures are • There should be a double door entry with a changing
of paramount importance in managing patients with room and nursing station.
COVID-19 infection.
• All healthcare workers should use PPE (triple layer
Triage area surgical mask, eye protection, gloves, gown and shoe
cover) when entering a patient room and remove PPE
• Encourage all patients to wear masks. All suspected
when leaving.
patients and caretakers should be provided with a triple
layer surgical mask and advice patients to keep 1-metre • If possible, use either disposable or dedicated
distance between them. Advice patients to perform equipment (e.g. stethoscopes, blood pressure cuffs and
hand hygiene after coming in contact with respiratory thermometers). Equipment which is reused should be
secretions. Health care workers in the triage area disinfected appropriately.
should wear N95 masks, face shields, gowns and
gloves. • Place an appropriate container with a lid outside the
door for equipment that requires disinfection or
• Apply droplet precautions when working within 1 - 2 sterilization.
metres of the patient using a triple-layer mask and face
shield or goggles. • Avoid patient movement and transport unless
necessary.
• Use PPE while entering the room with a triple layer
mask, gown and goggles and remove when leaving. • Aerosol-generating procedures (i.e. open suctioning
of the respiratory tract, intubation, bronchoscopy,
• Use dedicated /disposable equipment when possible. cardiopulmonary resuscitation) whenever possible,
should be done in adequately ventilated single rooms,
• Aerosol precautions should be taken while doing preferably negative pressure rooms with minimum of
aerosol-generating procedures by donning complete 12 air changes per hour or at least 160 litres/second/
PPE, including N95 mask.6 patient in facilities with natural ventilation.
• Disinfection of equipment, cleaning of patient’s These rooms may have stand alone air-conditioning.
surrounding and safe disposal of waste are also part These areas should not be a part of the central
of IPC measures. air-conditioning. If air-conditioning is not available
negative pressure could also be created through putting
Hand hygiene up 3-4 exhaust fans driving the air out of the room.
These procedures should be done after donning
Perform hand hygiene with alcohol-based hand rub for 20
complete PPE, including gloves, long-sleeved gowns,
seconds or wash hands with soap and water for 40 seconds
eye protection, and fit tested particulate N 95 masks.
before and after touching patient, using washrooms, taking
food, donning and doffing of PPE including mask and also • Used PPEs should be disposed of as per the bio-
after coughing, sneezing, handling garbage, touching mask medical waste management guidelines. Ensure these
or soiled PPE. bins (dirty) are inside the isolation areas.

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Indian Journal of Practical Pediatrics 2020;22(2) : 159

Cleaning and disinfection of the environment Box 4. Rational use of PPE for inter
1% freshly prepared sodium hypochlorite solution can hospital transport
be used as a disinfectant for cleaning and disinfection. • Driving the ambulance (Low risk) - Triple-layer
A contact time of at least 10 minutes is recommended. surgical mask gloves
70% alcohol-based disinfectants may be used for
disinfecting surfaces where bleach is not suitable • Transporting patients, not on any assisted ventilation
(e.g. metals). Wear heavy-duty/disposable gloves, (Moderate risk) - N-95 mask Gloves
disposable long-sleeved gowns, eye goggles or a face • Management of SARI patient while transporting
shield, and triple-layer surgical mask while cleaning the (High risk) - The full complement of PPE
area. Wipe all frequently touched areas (e.g. doorknobs,
• When aerosol-generating procedures are anticipated
lift buttons, handrails, armrests, tables, keyboards, switches,
etc.) every 3 - 4 hours. Low touch areas like wall and Before transport
mirror should be wiped daily once. Clean toilet surfaces
with 1% sodium hypochlorite solution or chemical Both the emergency medical technician (EMT) and
disinfectant. Wash linen/fabrics preferably using the hot driver of an ambulance should wear PPE while handling,
water cycle. For hot-water laundry cycles, wash with managing and transporting the COVID-19 identified/
detergent or disinfectant in the water at 70oC for at least suspect patients. Patient and attendant should be provided
25 minutes. Discard cleaning items made of cloth and with a triple layer mask and gloves. Only one caregiver
absorbent materials, e.g. mop head and wiping cloths, into should be allowed to accompany a patient. The identified
biohazard bags after cleaning and disinfecting each area. health facility should be contacted beforehand for facility
Wear a new pair of gloves and fasten the double-bagged preparedness and readiness. Treatment summary, vitals at
biohazard bag with a cable tie. Buckets can be disinfected reference and referral indication should be documented
by soaking in disinfectant or bleach solution or rinsing in
Management on board
hot water before filling.
Monitor vitals during transport. Give
Transport of infectious patients9
supplementary O2 at 5 L/min and titrate flow rates to reach
Transport of infectious patients should be limited to target SpO2 >90%. If a patient is on a ventilator, follow
movement considered medically essential by the clinician. ventilator management protocols.
The patient should be dressed in a mask and gown and Post transport
covered in a sheet. For quarantine isolation, the patient
may be transported in a fully enclosed transport cell or At the receiving hospital, hand over the patient and
isolator with a filtered air supply and exhaust. The transport details of medical interventions if any, during transport.
personnel should remove existing PPE, clean hands and PPEs should be taken off as per protocol followed by hand
apply clean PPE before transporting. The destination unit washing. The biomedical waste generated (including PPE)
should be notified before transport. It is preferable to should be disposed of in a biohazard bag (yellow bag).
transport patient through service or staff corridors than Inside of it should be sprayed with sodium hypochlorite
public corridors. The nominated lift and corridor should (1%) and after tying the exterior should also be sprayed
be isolated from public and staff before transport and with the same.
should be cleaned following transit of an infectious patient.
Disinfection of ambulance
Planning inter-facility transfer of COVID-19
All surfaces that may have come in contact with the
patients
patient or materials contaminated during patient care (e.g.
Ideally, there should be ambulances specifically stretcher, rails, control panels, floors, walls and work
identified to transport COVID-19 patients. It may be needed surfaces) should be thoroughly cleaned and disinfected
to transport patients from home to hospital or from one using 1% sodium hypochlorite solution. Clean and disinfect
hospital to another. Ambulance staff should be trained about reusable patient-care equipment before use on another
common infection prevention and control practices, patient with an alcohol-based rub. Cleaning of all surfaces
including the use of personal protective equipment should be done morning, evening and after every use with
(Box 4). soap/detergent and water.

47
Indian Journal of Practical Pediatrics 2020;22(2) : 160

Points to Remember 2. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al.

Epidemiology of COVID-19 Among Children in China.
• COVID-19 is rarer in children (1- 2% ). Pediatrics 2020, 145 (6); e20200702. DOI: https://doi.org/
• All suspected of having COVID-19 exposure or 10.1542/peds.2020-0702. Accessed on 25th May, 2020.
infection with mild symptoms should be advised 3. Wu Z, McGoogan JM. Characteristics of and Important
quarantine at home or in isolation centres. Lessons From the Coronavirus Disease 2019 (COVID-19)
Outbreak in China: Summary of a Report of 72 314 Cases
• All children with suspected COVID-19 infection From the Chinese Center for Disease Control and
should be categorized into three categories, Category Prevention. JAMA 2020; 323(13):1239-1242.
A, B and C. 4. Royal College of Paediatrics and Child Health Guidance-
Paediatric multisystem inflammatory syndrome temporally
• Category C is a child with critical symptoms like
associated with COVID-19 2020. Available from https://
altered sensorium, shock or respiratory distress or a www.rcpch.ac.uk/resources/guidance-pediatric-
SpO2 < 94%. multisystem-inflammatory-syndrome-temporally-
• Both clinical and laboratory monitoring are essential associated-COVID-19. Accessed on 21st May, 2020.
at periodic interval to decide escalation or 5. Viner RM, Whittaker E. Kawasaki-like disease: emerging
deescalation of therapy. complication during the COVID-19 pandemic. The Lancet
2020 DOI: https://doi.org/10.1016/S0140-6736(20)31129.
• Non invasive ventilatory support is preferred unless Accessed on 21st May, 2020.
child deteriorates, where intubation and mechanical 6. Ministry of health and family welfare. Guidelines for home
ventilation is needed. quarantine.pdf [Internet]. Available from: https://
www.mohfw.gov.in/pdf/ Guidelines for home quarantine.
• Even though there are no proven drugs, those tried pdf. Accessed on 21st May, 2020.
in clinical trial settings include hydroxychloroquine 7. Ministry of health and family welfare. Revised National
/ chloroquine, lopinavir / ritonavir, remedesivir, Clinical Management Guideline for COVID-19 [Internet].
nitazoxanide and ivermectin. Available from: https://www.mohfw.gov.in/pdf/Revised
• Safety of the health care workers and others are National Clinical Management Guideline for COVID-19.
Last accessed on 21st May, 2020.
important at every stage right from triage, admission
8. Gattinoni L, Chiumello D, Caironi P, Busana M,
areas and during transport.
Romitti F, Brazzi L, et al. COVID-19 pneumonia: different
• Hand hygiene, proper donning and doffing of the respiratory treatments for different phenotypes? Intensive
PPEs and environmental cleaning are extremely Care Med 2020 Apr 1-4. s00134-020-06033-2.
important. doi:10.1007/s00134-020-06033-2.
9. Ministry of Health & Family Welfare Government of India;
References National Centre for Disease Control. COVID -19 Outbreak
1. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. Guidelines for Setting up Isolation Facility/Ward (2020).
SARS-CoV-2 Infection in Children. N EngJ Med 2020; Available from: https://ncdc.gov.in/WriteRead Data/l892s/
382(17):1663-1665. 42417646181584529159.pdf. Accessed on 21st May, 2020.

CLIPPINGS

Tears do not carry corona.

COVID-19: Low risk of coronavirus spreading through tears.
While researchers are certain that coronavirus spreads through mucus and droplets expelled by coughing or
sneezing, it is unclear if the virus is spread through other body fluids, such as tears. Today’s just-published study
offers evidence that it is unlikely that infected patients are shedding virus through their tears, with one important
caveat. None of the patients in the study had conjunctivitis, also known as pink eye. However, health officials
believe pink eye develops in just 1 percent to 3 percent of people with coronavirus. The study’s authors conclude
that their findings, coupled with the low incidence of pink eye among infected patients, suggests that the risk of
virus transmission through tears is low.
American Academy of Ophthalmology: COVID-19: Low risk of coronavirus spreading through tears.
ScienceDaily, 25th March, 2020. Available from www.sciencedaily.com/releases/2020/03/200325143826.htm.
Last accessed on 14th June, 2020.
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Indian Journal of Practical Pediatrics 2020;22(2) : 161

COVID - 19

CRITICAL CARE MANAGEMENT OF in children, good outcomes are possible. The role of specific
PEDIATRIC COVID-19 therapies is unclear and a brief review of medication is
presented.
*Hari Krishnan Kanthimathinathan
**Manu Sundaram Keywords: COVID-19, Pediatric inflammatory
***Santosh Sundararajan multisystem syndrome, Temporally associated with
****Padmanabhan Ramnarayan SARS-CoV-2.
*****Barnaby R Scholefield Children have been relatively less affected than adults
in both frequency and severity of COVID-19 caused by
Abstract: Children tend to have relatively milder the SARS-CoV-2 virus.1 Given the rarity of severe disease
COVID-19 illness compared to adults. However, a small in children, international critical care community response,
proportion of children may need critical care support either including in the USA and UK, has largely been focused on
due to hypoxic respiratory failure or due to multi-system expansion of adult critical care units and redeployment of
inflammatory syndrome (Pediatric inflammatory personnel and equipment from pediatric critical care into
multisystem syndrome, temporally associated with adult critical care units to cope with the surge in numbers
SARS-CoV-2). While the principles of management are of critically ill adults with COVID-19. While children
consistent with any other severe acute respiratory illness, needing critical care with COVID-19 is a relatively rare
there are numerous challenges to ensure that the healthcare occurrence, severe disease and COVID-19 related deaths
workers are adequately protected. Significant planning and in children have also been reported.2 More recently,
prior preparation are required to overcome these a possibly SARS-CoV-2 related, multi-system
challenges. Even in the rare circumstances of severe illness inflammatory syndrome with overlapping features of
* Consultant Pediatric Intensivist, Kawasaki disease and toxic shock syndrome affecting
Birmingham Children’s Hospital, children has been reported.3 While debate about appropriate
Birmingham Clinical Trials Unit, nomenclature for this condition is still ongoing, it is
University of Birmingham, UK. currently referred to as ‘pediatric inflammatory
** Attending Physician, multisystem syndrome, temporally associated with
Division of Critical Care, SARS-CoV-2’ (PIMS-TS). 4 It is therefore of utmost
Sidra Medicine, Doha, Qatar
importance that the pediatric critical care community is
Assistant Professor of Clinical Pediatrics
well versed with strategies and considerations for managing
Weill Cornell Medicine, Doha,Qatar.
children with confirmed or suspected COVID-19.
*** Consultant Pediatric Intensivist,
Leeds Children’s Hospital, PICU admission- Indications
Leeds, UK.
Assessment of children should follow established
**** Consultant Pediatric Intensivist, institutional policies. However, given the high infectivity
Pediatric Intensive Care Unit,
of SARS-CoV-2 virus, risk-assessment to identify
St Mary’s Hospital, London, UK.
Children’s Acute Transport Service, appropriate level of personal protective equipment (PPE)
Great Ormond Street Hospital to protect the health care workers (HCW) should be
NHS Foundation Trust, performed. This may include obtaining information about
NIHR Biomedical Research Centre, London, UK. symptoms and signs, travel, contact history and the results
***** Consultant Pediatric Intensivist, of any recent tests for SARS-CoV-2 virus before reviewing
Birmingham Children’s Hospital, the children. Where this is not practical or feasible in
UK & Birmingham Acute Care Research Group, situations when urgent assessment is required, high level
Institute of Inflammation and Ageing, of personal protective equipment (PPE) including that used
University of Birmingham, Birmingham, UK. for aerosol generating procedures (AGP) may be the safest
email: dr.h.krishnan@gmail.com option. This ‘full PPE’ includes water-repellent protective
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Indian Journal of Practical Pediatrics 2020;22(2) : 162

body suit or long-sleeved gown, double gloves, wipeable Where possible, children with suspected COVID-19
shoes or shoe covers, N95 mask or filtering face piece 3 should be treated in single-occupancy negative pressure
(FFP3) or FFP2 mask fit-tested for each staff member and cubicles, at least until COVID-19 is excluded with
visor/goggles ± head cap. There is no clear evidence to reasonable certainty. Where this is not possible, every effort
suggest a different threshold for PICU admission related should be made to minimise exposure of other patients
to COVID-19 infection compared to other childhood admitted to PICU for reasons unrelated to COVID-19.
pneumonias or severe acute respiratory infections (SARI). Consideration of additional visiting restrictions and
In general, the following clinical scenarios may necessitate arrangements for isolation of parent/carers along with the
a PICU admission. children where appropriate may be required. Significant
• Requirement for significant respiratory support that planning and re-organisation of the physical ICU footprint
cannot be provided elsewhere such as non-invasive and staffing models may be required to ensure that this is
or invasive ventilation. This may be due to hypoxia, possible. Communication between team members can be
hypercarbia or increased work of breathing. difficult while wearing PPE. Similarly the use of phones,
computers and other resources may be limited inside the
• Requirement for cardiovascular support including cubicles with COVID-19 patients. Working in full PPE for
multiple fluid boluses or inotropes. This may be prolonged periods may cause dehydration of the health care
because of hyperinflammatory syndrome, myocarditis worker (HCW). It is important to stress, however, that while
or significant co-infections. significant changes may be required for infection
• Deterioration of neurological status. This may be due prevention and control purposes, the clinical management
to direct COVID-19 related neurological principles of a child with COVID-19 are identical to any
complications (e.g. seizures, encephalopathy) or other SARI.
related to respiratory complications such as hypoxia.
Respiratory failure - Management
• Any child considered to be at risk of further
deterioration requiring continuous or close monitoring There is no specific evidence to guide a different
requiring higher nurse: patient ratios. management strategy for respiratory failure in children with
COVID-19, compared to children with other causes of
PICU management - General principles SARI. However, minimising HCW’ exposure to aerosols
Hypoxic respiratory failure has been widely reported by reducing AGP and where this is unavoidable, using
in adults with SARS-CoV-2 infection and is the most appropriate PPE precautions is the key.5 Having minimal
common indication for ICU admission. Respiratory illness number of personnel, reducing equipment in close
related to COVID-19 in children may resemble other causes proximity, decontamination of exposed equipment, use of
of SARI including other bacterial or viral pneumonias. disposable equipment where possible are all important.
While characteristic radiological and laboratory features Significant uncertainties related to procedures which are
have been described in adults, non-specific changes are associated with aerosol generation exists. While there is a
the norm in children with COVID-19. A high-index of school of thought that early invasive ventilation, avoiding
suspicion and low threshold for testing for SARS-CoV-2 non-invasive ventilation and/or high flow nasal cannula
antigen by PCR is required. Due to sub-optimal sensitivity (HFNC) oxygen therapy minimises HCW exposure to
of the SARS-CoV-2 PCR test, a single negative test is not aerosols, it may not be practicable or safe in all
sufficient to exclude COVID-19 with high-level of certainty circumstances. Therefore, step-wise escalation of
in patients with a high pre-test probability. The pre-test respiratory support as with other causes of SARI may be
probability also depends on the population prevalence of the best course of action in children with COVID-19 also.6
COVID-19 and therefore will need to be interpreted in Management principles for ARDS in adults with
context of wider picture of the stage of the pandemic within COVID-19 may largely apply to pediatric critical care
the local area. Therefore repeat testing with nasal, throat management also. An informative summary of escalation
or nasopharyngeal swabs in patients who are not invasively of respiratory support and management of COVID-19
ventilated or lower airway specimen such as endotracheal related acute respiratory distress syndrome (ARDS) can
aspirates in invasively ventilated patients may be required. be found in website of ‘The Society of critical Care
Two or more tests may be required before full PPE Medicine’.7
precautions are stepped down to droplet PPE precautions
High flow nasal cannula (HFNC) oxygen therapy
(aprons, gloves, fluid-repellent surgical mask ± visor/
goggles), especially in those admitted with a SARI without Children with hypoxia (oxygen saturation <92%)
an alternative diagnosis. should receive supplemental oxygen. In children who
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Indian Journal of Practical Pediatrics 2020;22(2) : 163

require higher concentration of supplemental oxygen, be followed. Initial setting should aim to achieve tidal
heated and humidified oxygen with HFNC may be well volumes between 4 to 8 mL/kg of ideal body weight, with
tolerated and may reduce the need for invasive ventilation. a PEEP between 6 to 10 cm H2O and plateau pressure under
There is limited evidence behind the concerns about aerosol 28 cm H2O.10,11 Permissive hypoxia (SpO2 88-92% if PEEP
generation due to HFNC. In fact a recent study showed >10, or else 92-97% if PEEP <10cm H2O) and permissive
that the aerosol production from HFNC was no worse than hypercapnia (if pH >7.15) are acceptable to achieve optimal
spontaneous respiration regardless of presence or absence lung protection.10, 11 Deep sedation with or without muscle
of cough and regardless of higher or lower flows used in relaxation may be needed to facilitate this.
HFNC.8 Some North American centres do not consider
HFNC as an AGP. It is probably safe to use HFNC for Prone position has been thought to provide survival
children with mild-moderate disease severity, especially if advantage in adults with severe hypoxemia (PaO2/ FiO2
the HCW uses full PPE and children are nursed in cubicles. ratio < 150). Prone ventilation can improve oxygenation
Routine monitoring of heart rate, respiratory rate, fractional and lung homogeneity in children, although a survival
inspired oxygen (FiO2), work of breathing and comfort advantage has not been demonstrated. 12 Proning is
levels are essential to assess the effectiveness of HFNC recommended for 12-16 hours/day in adults and due
therapy. In fact, nearly a quarter of the children in the North precaution needs to be taken to avoid complications like
American cohort of COVID-19 were managed with HFNC pressure sores and ET tube obstruction/displacement. It is
only.2 HFNC therapy therefore is a useful immediate likely that pediatric critical care units have had already
respiratory support. However, treatment failure needs to experience with proning and have set policies and
be promptly recognised and respiratory support rapidly procedure which would help them to adapt to it. For e.g.,
escalated to either non-invasive ventilation (NIV) or adaptation would need to ensure that disconnection of
invasive mechanical ventilation. ventilator circuit does not occur.

Non-invasive ventilation Trial of inhaled Nitric Oxide is warranted in children

with persistent hypoxemia. High frequency oscillatory
NIV using a full face or oro nasal mask interface can ventilation (HFOV) has been used in neonates and children
be tried in selected patients based on local experience. with severe hypoxemia as a rescue therapy. However, the
Bubble CPAP may especially be a useful mode of support disadvantage with HFOV is that it is an open circuit with
in young infants. As with HFNC, effectiveness and response potentially significant aerosol generation. HFOV circuits
to therapy should be carefully evaluated. Escalation to with viral filters are available and are strongly
invasive ventilation should not be delayed especially in recommended if that is considered.
those children with a rapidly deteriorating disease
trajectory. Intubation must be recommended if there is no Extra-corporeal oxygenation
improvement in oxygenation (target SpO2 92 - 97% and
Extra-corporeal oxygenation (ECMO) has been used
FiO2 < 0.6) within 60-90 minutes of initiating NIV.9 As
in adults with SARS-CoV-2 in established and adequately
with HFNC, the risk associated with aerosol generation
resourced ECMO centres with variable outcome. This has
and exposure to HCW should be carefully considered and
usually been necessitated for refractory hypoxemia despite
appropriate PPE worn.
conventional ventilator management strategies including
Invasive ventilation the use of prone positioning and inhaled nitric oxide.
Very few children with COVID-19 have required ECMO.13
Strategies to minimise HCW protection from aerosols
Children have also been placed on ECMO for PIMS-TS
during invasive mechanical ventilation of suspected or
(rather than acute COVID-19) for cardiovascular support
confirmed COVID-19, may include the use of appropriate
if significant myocardial impairment exists.3 Given the
full PPE, inline suction, minimise circuit disconnection,
rarity, it is unlikely that clearly defined indications for
temporary clamping of endotracheal tube (ETT) when
ECMO support in children with COVID-19 can be agreed
disconnection is essential, passive humidification with a
upon. Individualised decision making with adaptations of
heat moisture exchanger (HME) filter rather than active
existing ECMO guidelines and wider consultation with
humidification, viral filter in the expiratory limb of the
various team-members will therefore be required.
ventilator circuit and pre-attached viral filters in bagging
Key components of planning for ECMO use during a
circuits for use in emergencies.
pandemic include: resource planning, personnel
In children requiring mechanical ventilation, assignment, training, infection control on ECMO, planning
established strategies for lung protective ventilation should for ECMO transfers etc.14 The use of ECMO should be
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Indian Journal of Practical Pediatrics 2020;22(2) : 164

restricted to experienced centres and the effect on resource guidelines. However, familiarity is the key. Routine
utilisation in the midst of a pandemic should be carefully induction medications used by pediatric critical care
considered. physicians to provide optimal intubating conditions in other
critically ill children can also be used for children with
Other supportive care COVID-19. This often includes a combination of ketamine,
Judicious fluid management is the key to the care of and/or an opioid and/or a benzodiazepine. Bag and mask
any critically ill child. Fluid overload is associated with ventilation is avoided to limit aerosol generation, if clinical
increase in morbidity and mortality in critically ill children. situation permits. If required, as low a tidal volume as
Following restoration of intravascular volume, a restriction possible with a low respiratory rate may be prudent. A heat
of daily allowance to 70-80% of calculated fluid moisture exchange (HME) filter can be placed between
requirement using Holliday-Segar formula is a good the mask and the bagging circuit. Prior to connecting to
starting point. Fluid balance should be assessed clinically ventilator, the ETT can be temporarily clamped while
and using input/output chart daily, allowance made for attaching to the ventilator circuit. Viral filters are
ongoing fever and associated insensible losses and with recommended in the expiratory limb (between the circuit
measured body weight when feasible and safe to do so. and machine), but significant variations in compatibility
Enteral feeding should be commenced at the earliest based on the make and model of the ventilators may exist.
possible opportunity, if safe to do so. Empirical antibiotics Extubation may also produce significant aerosols and
are justified until a diagnosis is established and/or therefore similar appropriate precautions apply.
co-infections are excluded even if the SARS-CoV-2 PCR
is positive. Choice of antibiotics depends on local Intra-and inter-hospital transport considerations
prevalence of the various bacteria.
The key principles relevant to the transport of a child
Other considerations with COVID-19, whether within the hospital (e.g. for a
CT scan) or between hospitals (e.g. for enhanced care),
Intubation and extubation are similar. The primary consideration is always to maintain
Intubation is probably the pediatric critical care patient safety; however, the additional consideration of staff
procedure associated with the most amount of aerosol safety is important when dealing with COVID-19 due to
production. Therefore it is done with utmost care with PPE its highly infectious nature.
including careful donning and doffing and use of a donning/ Preparation for transport: It is important to identify early,
doffing buddy. Medical literature, especially the social the COVID-19 status of the patient, either suspected (based
media, is flooded with various improvisations of the on the case definition) or confirmed by laboratory testing.
procedure to minimise HCW exposure to aerosols. COVID-19 status will affect several aspects of the
Examples include perspex boxes, plastic cling film transport: the type of PPE needed, the seniority of staff
covering the patient etc. However, the unproven but involved (most senior personnel), logistics of moving the
potential additional protection offered by these devices patient (ground ambulance, air ambulance, trolley push
should be carefully weighed against difficult ergonomics, within the hospital), the choice of respiratory support
human factors, operator difficulty related to unfamiliar provided (non-invasive versus invasive ventilation) and
equipment, spreading the infection while removing the appropriate decontamination of transport equipment.
additional device and consequences of intubation failure. All staff involved in the transport of children with
Regardless of any new equipment used, team simulation COVID-19 should be in full PPE to protect against AGP.16
for intubating a COVID-19 patient is essential to fine tune Common AGP performed during transport include HFNC,
the procedure and adapt it to the local environment and NIV, endotracheal intubation and open endotracheal
personnel. The challenges of performing pediatric critical suction. If patients are self-ventilating, a surgical face mask
care procedures while wearing full PPE cannot be under- can be considered to minimise aerosol spread.
estimated. The use of a checklist, such as the one produced
in conjunction with the UK Pediatric Intensive Care Society Airway and respiratory management: Inter-hospital
can be invaluable.15 It is recommended that the most transfers of children on HFNC or NIV are challenging due
experienced airway operator intubates the child and where to aerosolisation risk - staff must be in full PPE throughout
possible cuffed endotracheal tubes should be used to and the ambulance must not re-circulate air (instead, should
minimise leak around the tube. The use of video be set to exhaust). Where possible, NIV should be delivered
laryngoscopes has been recommended in several using dual-limb circuits and unvented face masks.

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Indian Journal of Practical Pediatrics 2020;22(2) : 165

Alternatively, a high-efficiency viral filter should be In essence, therefore the adaptation required for
attached proximal to the expiratory leak.9 Emergency patients with suspected or confirmed COVID-19 are two-
intubation is a high-risk procedure even without the fold, i) Donning full PPE prior to any contact with patients
challenges of full PPE and therefore the need for intubation to commence CPR and ii) Early intubation, as soon as it is
during patient transport should be avoided wherever practical, following initial bag and mask ventilation.
possible by early identification of NIV failure and early Potential delays in initiating CPR can be minimised by
intubation.10 Use of a standardised checklist for intubation, close monitoring, anticipation of deterioration,
as highlighted earlier, is recommended. 15 Transport preparedness and simulation of donning PPE.
ventilators are often turbine-driven and use ambient air
rather than compressed medical air from cylinders, Specific therapies for SARS-CoV-2 infection
therefore viral filters are recommended on the inspiratory The vast majority of children with COVID-19 only
limb of the circuit (to prevent the patient being infected) require routine supportive treatment as described above.
as well as expiratory limb of the circuit (to prevent the However, a number of specific therapies to treat
ventilator being contaminated by the patient). COVID-19 have been proposed, especially in adults given
Patient handover: To avoid contamination of clean areas that the severity of disease and case-fatality rate are
of the receiving hospital, a secure and dedicated pathway significantly worse than in children. Many of these are
for accessing the relevant areas (e.g. ICU, CT scanner) repurposed medications used in COVID-19 because of
should be identified and followed during intra and inter- in-vitro evidence or hypotheses only. None have been
hospital transfer. Following verbal handover, transfer convincingly shown to be of benefit yet, in either adults or
documentation may be transmitted by electronic means, children. Adults have been recruited to several large scale
where possible, due to the risk of contamination of paper clinical trials.20 Therefore, literature related to this is rapidly
notes during transport. evolving and multiple trials are due to publish their findings
within the next few weeks to months. A summary of
Equipment and decontamination: To avoid equipment
mechanism of action, dose ranges and recommendations
wastage due to contamination, they should be in wipeable,
for some of the COVID-19 specific medications is listed
closed, small pouches (e.g. airway equipment, resuscitation
in Table I.21-23 Additional details related to a few of the
drugs) that should be opened only if required.
proposed specific therapies are provided below.
Decontamination of equipment such as the patient trolley,
transport ventilator, infusion pumps and patient monitor Remdesivir: In the United States, the Food and Drug
should be performed using universal detergent wipes Administration (FDA) authorized the emergency use of
followed by a 1:1000 chlorine-based solution/wipes. remdesivir to treat hospitalized adult and pediatric patients
The exposed surfaces of the ambulance will require similar with suspected or laboratory confirmed SARS-CoV-2
decontamination, especially if an AGP was performed infection and severe COVID-19.24 Although, the double-
during transport. blind placebo controlled Adaptive COVID-19 Treatment
Cardiopulmonary resuscitation (CPR) Trial showed a significantly faster time to recovery in
hospitalized adults, the differences in mortality rate was
Cardiac arrest due to COVID-19 in children is an minimal and did not reach significance.25 Children were
extremely unlikely event. However, in children who excluded from this study. Therefore caution is warranted.
unfortunately have an in-hospital cardiac arrest, the
COVID-19 status may be unclear either because of unclear Chloroquine/Hydroxychloroquine: The repurposed anti-
history, awaiting test results, or because of a concern that malarial/immune-modulator medications, used sometimes
a repeat test is warranted due to the sequence of events in combination with a macrolide such as Azithromycin
leading to the cardiac arrest. In any case, HCW protection attracted significant media attention during the early stages
is an important consideration in CPR as with the other of the pandemic due to a much publicised study with
pediatric critical care aspects mentioned here. There is significant limitations. 26 239 clinical trials of either
limited evidence base related to status of CPR as an AGP.17 chloroquine or hydroxychloroquine are currently ongoing.20
However, it has been helpful that various life support Therefore it is likely that a definitive answer about
organisations have produced consistent consensus effectiveness of these medications will be obtained soon.
statements recommending that the HCW donning PPE Recently, data from a large-scale multi-national registry
before commencing CPR in patients with suspected or analysing drug regimens that used either
confirmed COVID-19 because of concerns related to hydroxychloroquine or chloroquine, with or without a
aerosol generation with CPR.18,19 macrolide for COVID-19 revealed an association with more
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Table I. Specific therapies in children with COVID-19 21- 23

Drug Mechanism of action Pediatric recommendations Dosing guidance*

Comments
Remdesivir Inhibits viral RNA - May be considered on a case- <40 kg: 5 mg/kg IV loading dose
dependent by-case basis in children with on day 1; then 2.5 mg/kg IV OD.
RNA polymerase severe disease unresponsive >40 kg: 200 mg IV loading dose
to standard management on day 1; then 100 mg IV OD.
without specific COVID-19 5-10 days
therapy
Chloroquine(CQ) Inhibits viral entry and May be considered on a case- CQ: 10mg/kg base stat followed
endocytosis. Inhibition of by-case basis in children with by 5mg/kg base BDHCQ: 8mg/kg
Hydroxychloroquine glycosylation of ACE-2 severe disease without access stat, followed by 4mg/kg BD for
(HCQ) receptor. Additionally, host to Remdesivir. 5 days.
immune-modulatory effects No evidence related to
postulated to be beneficial prophylaxis.
Co-administration with
Azithromycin not recommended.
Monitor QTc
Lopinavir-Ritonavir Inhibits proteolysis Recommendation unclear. 14 day-12 months: 16 mg/kg/dose
Do not co-administer with [Lopinavir dose]15-25kg: 200/
Ribavirin Major p450 50mg 26-35kg: 300/75mg >35kg:
interactions 400/100mg 12 hourly PO, BD,
5-14days
Tocilizumab Binds IL6 receptor and Has been used in COVID-19 <30 kg-12 mg/kg/dose
prevents IL6 activation cytokine storm in adults. >30 kg-8 mg/kg/dose IV infusion.
Limited pediatric data. Further single dose after 12h,
Recommendation unclear. if required.
May be considered in PIMS-TS
patients who are unresponsive
to standard management,
as part of clinical trial.
* Other drug dosing suggestions exist. Please consult local formulary prior to prescribing.

frequent ventricular arrhythmias and decreased survival Convalescent plasma: A systematic review and meta-
which was retracted later.27 This stresses the importance analysis of convalescent plasma for treatment of SARI of
of balancing hypothetical benefits of treating children with viral aetiologies suggested a significant reduction in
COVID-19 with specific therapies, against the real mortality.28 Indeed, various reports of improved outcomes
treatment related risks. with the use of convalescent plasma from donors with
sufficient titres of neutralizing antibody to SARS-CoV-2
Steroids: The role of steroids is unclear. There are concerns exist. However, the Surviving Sepsis campaign
that steroids may be associated with prolonged viral COVID-19 panel recommended against the routine use of
shedding and therefore not routinely recommended. convalescent plasma on the basis of limited trial evidence.7
However, there is a weak consensus for the use of steroids Important knowledge gaps regarding optimal titres of
in select circumstances such as refractory shock neutralizing antibodies to SARS-CoV-2 and availability
(low, replacement dose of steroids) or in patients who fail of a sufficiently large enough donor pool with optimal
to improve with conventional management for severe antibody titres exist. However further trials are ongoing,
ARDS.7 including at least two in India.20
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Indian Journal of Practical Pediatrics 2020;22(2) : 167

Pediatric Inflammatory Multisystem activation syndrome or hemophagocytic lymphohistio-

Syndrome, Temporally associated with cytosis. This syndrome is commonly being referred to as
SARS-CoV-2 (PIMS-TS) PIMS-TS or Multisystem Inflammatory Syndrome in
Children (MIS-C).4, 29
In April 2020, pediatric critical care clinicians in the
UK and elsewhere witnessed clusters of children requiring Case definition: The UK Royal College of Paediatrics and
PICU admission for an inflammatory syndrome which Child Health (RCPCH), Centers for Disease control (CDC)
appeared to have overlapping features of Kawasaki disease and prevention in the US and the World Health
(KD), toxic shock syndrome and potentially macrophage Organization (WHO) have all put forward case definitions

Table II. Case definition and additional features of PIMS-TS, adapted from the UK Royal College
of Pediatrics and Child Health guidelines
RCPCH Case Definition
1. A child presenting with persistent fever, inflammation (neutrophilia, elevated CRP and lymphopenia) and evidence
of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder)
with additional features listed below.This may include children fulfilling full or partial criteria for Kawasaki disease.
2. Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes,
infections associated with myocarditis such as enterovirus (waiting for results of these investigations should not
delay seeking expert advice).
3. SARS-CoV-2 PCR testing may be positive or negative
Additional Features
Clinical: Imaging and ECG: Laboratory:
All: • Echocardiogram & ECG - myocarditis, All:
• Persistent fever >38.5°C valvulitis, pericardial effusion, • Abnormal fibrinogen
coronary artery dilatation • Absence of potential causative
Most: • CXR - patchy symmetrical infiltrates, organisms (other than SARS-CoV-2)
• Oxygen requirement pleural effusion • High CRP
• Hypotension • High D-Dimers
Some: • US abdomen - colitis, ileitis, lymphadenopathy, • High ferritin
• Abdominal pain ascites, hepatosplenomegaly • Hypoalbuminemia
• Confusion • Lymphopenia
• Conjunctivitis • CT chest – patchy symmetrical infiltrates, • Neutrophilia in most - normal
• Cough pleural effusion, may demonstrate coronary neutrophils in some
• Diarrhoea artery abnormalities if with contrast Some:
• Headache • Acute kidney injury
• Lymphadenopathy • Anemia
• Mucus membrane changes • Coagulopathy
• Neck swelling • High IL-10
• Rash • High IL-6
• Respiratory symptoms • Neutrophilia
• Sore throat • Proteinuria
• Swollen hands and feet • Raised CK
• Syncope • Raised LDH
• Vomiting • Raised triglycerides
• Raised troponin
• Thrombocytopenia
• Transaminitis
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Indian Journal of Practical Pediatrics 2020;22(2) : 168

for this condition. 30-32 While subtle variations exist, for several days. While the CDC case definition suggested
they refer to a combination of fever, evidence of fever for longer than 24 hours, the WHO case definition
hyper-inflammation, multiple organ involvement, a link to requires presence of persistent fever of at least 3 days.
SARS-CoV-2 infection and exclusion of other underlying Gastro-intestinal manifestations such as abdominal pain,
etiologies. The exact nature of this illness and its diarrhea and vomiting were common. The abdominal signs
association with COVID-19 is far from clear at this and symptoms may be severe enough to mimic an acute
moment. While the RCPCH case definition (Table II) abdomen such as appendicitis in some patients. Rash and
merely mentions that the SARS-CoV-2 PCR may be mucositis were also common, however, they were less
positive or negative, the CDC and WHO criteria go further consistent than GI symptoms. Patients were noted to have
in suggesting an aetiological link with SARS-CoV-2 high inflammatory markers (C-reactive protein,
serology testing or contact with COVID-19. Indeed, several procalcitonin, ferritin). Various interleukins, especially
patients with PIMS-TS were found to have either IL-6 levels may be elevated. CRP has good correlation to
SARS-CoV-2 RNA by PCR or more commonly IgG and IL-6 levels and may be used as a proxy marker. Warm shock
IgM antibodies to SARS-CoV-2. 3,33 This raises the with significant vasoplegia requiring vasopressors is
possibility of this being an immune-mediated disease common. Myocarditis and development of coronary artery
process in children who had either asymptomatic or mildly aneurysms are the potentially life-threatening short and
symptomatic recent COVID-19 illness. long-term consequences respectively. Myocarditis and
reduced cardiac function have been severe enough in some
Clinical features and investigations: While some variability patients to necessitate ECMO support.3 Serial troponins,
within individual patients existed, they were generally older brain natriuretic peptides (BNP) or N-terminal-pro
(6-15 years of age) than the usual age-group affected by hormone brain natriuretic peptides (NT-proBNP), ECG and
KD (<5 years of age). Patients often presented with fever echocardiography may be useful to track the cardiac

Table III. Suggested investigations in children suspected to have PIMS-TS. Adapted from the
UK RCPCH guidelines
Blood Tests: Microbiology:
• Full blood count, blood film • Blood culture
• Urea, creatinine, electrolytes • Urine and stool culture
• Liver function tests • Throat swab culture
• CRP • Nasopharyngeal aspirate or throat swab for
• ESR respiratory virus /bacterial panel
• Glucose • Mycoplasma antibody titres
• Blood gas with lactate • Pneumococcal, Meningococcal, Group A
• Prothrombin time, partial thromboplastin time, fibrinogen Streptococci, Staph aureus Blood PCR
• D-Dimer [include locally prevalent pathogens]
• LDH • ASO Titre
• Triglycerides • EBV, CMV, Adenovirus, Parvovirus, Enterovirus
• Ferritin PCR on Blood
• Troponin I • Consider blood for enterotoxin/staph toxins
• BNP or NT-proBNP • Stool for virology
• Creatine kinase
• Vitamin D
• Amylase
• Save blood, serum sample (pre IVIG) for any other
investigations that may be required later
Cardiac investigations: SARS-CoV-2 Investigations:
• ECG • SARS-CoV-2 Respiratory PCR
• Echocardiogram • Consider SARS-CoV-2 PCR on stool and blood, if
available
• SARS-CoV-2 serology
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Indian Journal of Practical Pediatrics 2020;22(2) : 169

involvement and help prognosticate. Coagulation disciplinary team approach with members of pediatric
abnormalities such as elevated fibrinogen, elevated rheumatology, immunology, infectious diseases,
D-dimers, thrombocytopenia or thrombocytosis were also hematology and cardiology. Serial blood tests, ECG and
frequently observed. The implications of these are not yet echocardiography may be indicated for surveillance.
well understood. Heightened anxiety related to potential Frequency of monitoring and investigations has to be
for new thrombosis or embolism to occur exists. tailored to the individual depending on clinical, laboratory,
However, this has not been well characterised in the ECG, echocardiographic response. Longer term follow-up
literature as yet. Surveillance for thrombosis and of such patients may be essential, especially focusing on
precautions to prevent thrombosis from occurring are recovery of myocardial function and progression to
essential. A suggested list of investigations as per the UK coronary artery aneurysms. Information from global
RCPCH is provided in Table III. This needs adaptation to registries such as the recently established WHO Global
include investigations for ruling out common causes of COVID-19 Clinical Data Platform may help reduce some
sepsis as per the local situation. of the many uncertainties related to monitoring and
management of this new entity.32
Management: Given that this is a relatively new condition,
knowledge and understanding related to this disease is Conclusion
evolving. Mainstay of treatment is supportive care.
All patients should receive supportive therapies such as While children are relatively spared from the severity
empirical antibiotics tailored to the local prevalence of of COVID-19 infection, it is prudent for pediatric critical
bacteria, judicious fluid resuscitation and if required care physicians to get prepare. The challenges related to
inotropes and/or vasopressors. Many centres used managing children with COVID-19 span every level of an
intravenous immunoglobulin (IVIG), aspirin (commonly organisation from procurement, estates to physicians and
12.5mg/kg QDS, if no contra-indications exist) and steroids nurses. Simulation of a patient journey through the hospital
in line with existing guidelines for the apparently related including the critical care environment, with considerations
Kawasaki disease with shock.34 including parents, families and other non-COVID-19
patients, can be invaluable in highlighting the lessons that
If hyper-inflammation persisted, various other need to be learnt and adaptations that must be performed.
immunomodulators have also been tried on a case-by-case The challenges of communication and performing
basis such as anakinra, tocilizumab and infliximab; procedures while wearing full PPE cannot be
although it is unclear whether they improve longer term underestimated. By following good critical care practice
outcomes. Clear definitions of failure to respond to in airway, breathing and circulatory management with very
treatment and indications to consider these careful attention to personal protection of staff with PPE
immunomodulators are lacking. Tocilizumab has been practices and infection control for other patients, good
considered for its inhibitory effects on IL-6. Anakinra has outcome for children with COVID-19 can be achieved.
been used for blocking IL-1 receptor signalling which then Additional research into pharmacological treatments for
acts on other pro-inflammatory cytokines.35 Recovery of adults and children with COVID-19 and PIMS-TS are
myocardial function after intravenous immunoglobulin has needed to demonstrate their benefits and recommend use.
been reported.29 However, there is limited evidence base
to provide precise indications or to support one therapy Points to Remember
over the other. In fact, coronary artery aneurysms have been
reported to occur even in patients who had received • Though COVID-19 infection in children is less
tocilizumab for Kawasaki disease prior to this pandemic.36 frequent and need for critical care is a relatively
Concerns about re-activation of latent diseases such as rare occurrence, severe disease and COVID-19
tuberculosis must be borne in mind when related deaths have been reported.
immunomodulators are considered.
• Indications for PICU admissions are similar to other
The role of anti-coagulation in management of emergencies.
PIMS-TS is unclear. However, several centres have used
• In COVID-19 , step-wise escalation in respiratory
prophylactic low-molecular weight heparin after a case-
support is considered as best practice . Compared to
by-case consideration weighing up the risks and benefits.
the early days of pandemic, NIV and HFNC use is
The key principle underpinning management of such increasing since it is believed that HFNC does not
patients is individualised management with a multi- produce much aerosolisation.

57
Indian Journal of Practical Pediatrics 2020;22(2) : 170

• Supportive management with repurposed or Breathing Human Subjects. medRxiv 2020;2020.04.15.

unproven medications is practised widely and more 20066688. Available from: http://medrxiv.org/content/
evidence for or against will be available in the next early/2020/04/20/2020.04.15.20066688. Accessed on
weeks or months from the ongoing studies. 12th May, 2020.
9. ESPNIC. Practice recommendations for the management
• A new clinical presentation reported recently is the of children with suspected or proven COVID-19 infections
PIMS-TS, a possibly SARS-CoV-2 related, multi- from the Paediatric Mechanical Ventilation Consensus
system inflammatory syndrome with overlapping Conference (PEMVECC) and the section Respiratory
features of Kawasaki disease and toxic shock Failure from the ESPNIC. [cited 2020 May 22]. Available
syndrome. from: https://espnic-online.org/News/Latest-News/
Practice-recommendations-for-managing-children-with-
• While managing PIMS-TS, concerns about proven-or-suspected-COVID-19. Accessed on 22th May,
re-activation of latent diseases such as tuberculosis 2020.
must be borne in mind when immunomodulators are 10. Kneyber MCJ, de Luca D, Calderini E, Jarreau P-H,
considered. Javouhey E, Lopez-Herce J, et al. Recommendations for
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Indian Journal of Practical Pediatrics 2020;22(2) : 172

COVID - 19

NEONATAL COVID-19 The general information from the literature so far

indicates that neonatal COVID-19 infection may be
*Manigandan Chandrasekaran uncommon. Besides, it is generally acquired through
**Amish G Vora postnatal transmission rather than vertical transmission.
Abstract: Novel coronavirus infection is a disease caused Newborn infants with COVID-19 infection exhibit either
by severe acute respiratory syndrome coronavirus 2 and no symptoms or mild respiratory illness.5 Some researchers
named as coronavirus disease 2019. First confirmed case postulate that milder disease in newborn infants and
in adult was reported in December 2019 in China. Since young children is due to the relative immaturity of
then, research is being conducted in multiple sites in order angiotensin-converting enzyme 2 (ACE2) protein, which
to better define the epidemiology, clinical characteristics, usually acts as a receptor for SARS-CoV-2 in adults.6
prevention and treatment of severe acute respiratory Furthermore, the higher percentage of fetal hemoglobin in
syndrome-coronavirus-2 infection in adults. Few cases newborn infants may be protective over SARS-CoV-2.7
have been observed in children and newborn infants who With the current pandemic, there is an urgent need to
seem to have a milder form of clinical disease than other address certain pertinent issues- whether pregnant women
age groups. The purpose of this review is to summarize the who have confirmed COVID-19 infection are more likely
available evidence on severe acute respiratory syndrome- to spread the virus vertically to endanger the fetus, clinical
coronavirus-2 transmission, the associated clinical features and management of newborns born to those
presentation, outcomes and treatment in newborn infants affected mothers. A comprehensive review of the available
with the aim to provide adequate information to evidence regarding all such issues is presented.
neonatologists, pediatricians and obstetricians for
managing such patients. Vertical transmission

Keywords: COVID-19, Perinatal COVID, Neonatal Initial reports suggested that while severe acute
COVID, Corona virus, Vertical transmission. respiratory syndrome-coronavirus-2 (SARS-CoV-2)
infection could result in adverse pregnancy outcomes,
Since the first case in December 2019, the coronavirus newborn infants did not show any clinical signs of illness
disease 2019 (COVID-19) has spread rapidly across the and had negative viral testing.8,9 However, new evidence
world. As of May 20, 2020, the World Health Organization for this is being published often that contest the information
(WHO) had reported just over 5 million people infected from the earlier reports. A recent review found 27
with COVID-19 worldwide.1 At the same time, 1.1 Lakh publications describing 217 newborns born to mothers with
people were infected in India according to Ministry of COVID-19.10 They showed that 7 out of 217 newborns
Health and Family Welfare Department (MOHFW).2 (3%) had evidence of SARS-CoV-2 infection. Three had
During the earlier stage of the pandemic, older adults were positive serum levels of IgG and IgM antibodies with
reported to be more likely infected.3,4 However, with the negative PCR tests, and four had positive PCR tests.
sharp increase in the number of infections, the number of All positive infants had favorable neonatal outcomes with
pregnant women, newborn infants and children with no major morbidities. Thirty (14%) newborns were born
COVID-19 is also on the rise. through vaginal delivery and all were negative for
SARS CoV- 2 PCR. Vertical transmission during pregnancy
* Consultant Neonatologist, is thought to be unlikely in these cases as PCR testing on
Motherhood Hospital, Chennai.
placenta, umbilical cord, amniotic fluid, vaginal secretions
** Senior Consultant, and breast milk samples has been uniformly negative.
Pediatric and Neonatal Critical Care,
Likely explanation for this is the postnatal infection through
SRCC Children’s Hospital,
horizontal transmission. Another systematic review by
Mumbai.
Elshafeey et al., also presented similar findings from their
email: mani.manigandan@googlemail.com
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Indian Journal of Practical Pediatrics 2020;22(2) : 173

review of 33 studies and 385 pregnant women with (one maternal mortality and one woman on ECMO). One
COVID -19 infection.11 early neonatal death occurred due to complications of
prematurity following cesarean delivery at 34 weeks for
More recently, there are case reports indicating the
antepartum hemorrhage. All these three infants who died
possibility of vertical transmission. 12, 13 Sinelli et al.,
were PCR negative. Four (1.6%) newborns, delivered by
reported that the mother and newborn tested positive for
cesarean, had a positive RT-PCR test result and were
PCR from nasopharyngeal swab on day 2 of age. 12
classified as mild. They recovered well and were
The newborn required non-invasive ventilation with 30 %
discharged. Another three (1.4%) were positive for IgM
FiO2 for few days, but recovered well. In the second report,
antibodies and were asymptomatic or mildly symptomatic.
the nasopharyngeal swab of the newborn, taken at 16 hours
All three infants again recovered well and were discharged.
after delivery, was positive for SARS-CoV- 2 PCR, and
Two recent reports indicated that one newborn required
immunoglobulin IgM and IgG were negative. 13
ventilatory support for brief period, but recovered well and
This newborn was ventilated for 12 hours in the beginning,
another newborn with mild febrile illness with hypoxia
but recovered well soon. Both authors discussed the
who required non-invasive ventilation, also recovered
possibility of vertical transmission in these babies.
well.12, 13
Among the small number of pregnancies described
Laboratory features in the newborn infants may
until now, there is no strong evidence of vertical
include lymphopenia, elevated liver enzymes, coagulation
transmission to the neonate; however, women were
abnormalities and X-ray chest showing bilateral infiltrates
infected in the third trimester. The effects of the virus earlier
in the lungs suggestive of pneumonia.7 All clinical features
in pregnancy (first and second trimester) are yet to be
and laboratory features of newborns with PCR positive
known.
for SARS-CoV-2 are summarized in Table I.
Clinical features
Diagnosis
The extent of the disease severity in newborn infants
is difficult to describe with available limited data. Diagnosis of a newborn infant born to a suspected or
The incubation period may vary from 2-14 days with a COVID positive mother is imperative, but can be
median of 5 days. Newborn infants tend to get diseases challenging at times as the sensitivity of the test depends
that are milder and associated with better outcomes on the timing and sample. RT-PCR testing of nose and
compared to adults. 5 They can be asymptomatic most of throat swab for detection of SARS-CoV-2 nucleic acid has
the times or can present with mild symptoms like minimal been recommended as the confirmatory test for COVID-
respiratory distress. The review by Elshafeey et al, 19. Other alternative sample could be endotracheal aspirate.
discussed the clinical outcomes of newborn infants who FOGSI, NNF and IAP, have teamed up together recently
were born to 252 COVID positive mothers.11 Among the and published the criteria for testing newborns as follows.14
256 newborns (248 singleton and eight babies as four Whom to test: All newborn infants who have any one of
twins), the reported outcomes were, respiratory distress the following:
syndrome (4.7%), neonatal pneumonia (1.2%) and
disseminated intravascular coagulation (1.2%). Majority 1) History of exposure to COVID-19 positive adult
of newborns were asymptomatic. Three newborns died. (irrespective of symptoms), mother had COVID-19
Two stillbirths were reported for two critical women infection within 14 days before birth, history of contact

Table I. Clinical and laboratory features of all neonates who tested positive for
COVID-19, reported so far in the literature.
Clinical characteristics Laboratory characteristics
Asymptomatic Lymphopenia
Respiratory distress - mild to moderate Leukocytosis
Cough – sporadic Elevated transaminases
Mild fever Elevated cytokine levels (IL-6 and IL -10)
Cyanosis (without respiratory distress) X-ray Chest – normal or bilateral infiltrates
Feed intolerance
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Indian Journal of Practical Pediatrics 2020;22(2) : 174

with COVID-19 positive persons (including mother, Antenatal management

family members in the same household or direct
healthcare provider) in the postnatal period. Pregnant women should follow the same
recommendations as nonpregnant adults for avoiding
2) Irrespective of history of exposure: Presenting with exposure to the virus like social distancing, hand hygiene,
pneumonia or severe acute respiratory infection disinfecting surfaces and wearing a mask in public.
(SARI) that require hospitalization, with onset at more Pregnancy is a partially immunocompromised state,
than 48-72 hours of age, unless there is another however despite the fact that COVID-19 is known to cause
underlying illness that completely explains the severe life-threatening respiratory complications in adults,
respiratory signs and symptoms. especially the immunocompromised, there are no
When to do the test comparative data to determine whether pregnancy is a risk
factor for severe COVID-19. Pregnant women should be
a) At birth (if mother had COVID-19) or at detection of monitored and clinical manifestations are similar to those
the history of contact with COVID-19 positive person in nonpregnant individuals. 11 Pregnant women with
(postnatal exposure) confirmed COVID-19 should be managed with
b) If a sample is not obtained at birth due to logistic supportive care recommended for non-pregnant adults.
reasons, it should be obtained as soon as possible. Currently recommended management includes: oxygen
therapy/respiratory support for treatment of hypoxemic
When to do repeat test? respiratory failure, fluid therapy, antibiotics and
If the first test is negative, a repeat test should be done management of shock.14 All COVID-19 positive pregnant
after 5-14 days of birth/exposure. However, the test should women should be referred to designated COVID care
be done immediately, if new symptoms such as respiratory facility. In such COVID care facilities, three demarcated
distress, lethargy, seizures, apnea, refusal to feed, diarrhoea zones (clean, potentially contaminated, contaminated), each
appear. housing all the needed equipment and services for women
and newborns are required for management of non-COVID,
Management suspected and confirmed COVID-19 mothers.
The standards and facilities required for infection control
Management of newborn infants includes team work in these areas should be same as that for other adults with
involving obstetricians, neonatologists, staff nurses and suspected or confirmed COVID-19. Every pregnant woman
hospital management. Management flow chart is depicted should be triaged at entry and then allotted into one of the
in Fig.1. zones. If a pregnant woman, who delivers in a non-COVID
Personal protective equipment (PPE) facility, turns out to be COVID-19 positive, actions should
be taken as per the Ministry of Heath and Family Welfare
SARS-CoV-2 is a respiratory virus transmitted from and referred to COVID facility, and take steps to disinfect
person-to-person primarily by respiratory droplets. the non-COVID facility.14
Precautions have to be taken and personal protective
equipments have to be worn while taking care of newborn Antenatal steroids have proven benefits in neonatal
infants with COVID-19 positive mother. Following mortality and morbidity. American College of Obstetricians
definitions for precautions were given by AAP.15 and Gynecologists (ACOG) continues to recommend its
use in pregnant women between 24+0 and 33+6 weeks of
Droplet and contact precautions: Gown, gloves, standard gestation with suspected or confirmed COVID-19. 16
procedural mask and eye protection (either face shield or For pregnant women between 34+0 and 36+6 weeks of
goggles) should be used for most encounters with infants gestation, these decisions may need to be individualized,
born to mothers with COVID-19. weighing the neonatal benefits with the risks of potential
Airborne, contact and droplet precautions: Gown, harm to the pregnant woman.16 The use of magnesium
gloves, N95 respiratory mask with eye protection should sulfate for maternal seizure prophylaxis and/or neonatal
be used when patients require bag-mask ventilation, neuroprotection should be decided on a case-by-case
intubation, tracheal suctioning, nasal cannula oxygen at a basis.16
flow greater than 2 liters per minute/kilogram, continuous Delivery room management
positive airway pressure and/or positive pressure
ventilation of any type, given the potential for these The mode of delivery and anesthesia is best decided
supports to generate aerosols. as per maternal and fetal indications by the obstetric and
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Indian Journal of Practical Pediatrics 2020;22(2) : 175

Fig.1. Management of newborn infants born to the suspected or confirmed COVID-19

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Indian Journal of Practical Pediatrics 2020;22(2) : 176

anesthesia teams regardless of the COVID-19 status. be used to reduce viral dispersion if available.18
There is no evidence to suggest one mode of delivery is Addition of a filter can reduce efficiency by
preferred over the other.10 Delivery of a suspected or increasing mask leaks and so it is vital to understand
confirmed COVID-19 patient should rather take place in a and provide pressure accordingly while using the filter.
center with the capacity to care for critically ill adults and It is better to avoid filters in ELBW infants
newborns and in a negative pressure room if available. (birth weight <1000 grams) to avoid possible
The optimal location for neonatal stabilization and iatrogenic hypercapnia with subsequent
resuscitation could be in an adjacent room or the same intraventricular hemorrhage.
place at least 6 feet or 2 meters away from the mother with
• Consider use of aerosol box during intubation if
a physical barrier. To minimize exposure, the least number
available.
of personnel should enter the delivery room. Providers
should don appropriate PPE as mentioned above. Mother • The area providing respiratory support should be a
should perform hand hygiene and wear triple layer mask. negative air pressure area.

Neonatal resuscitation should be performed according • Closed ET suction circuit should be used, and a
to the Neonatal Resuscitation India, 3rd edition, published hydrophobic filter placed at the exhalation port.
by National Neonatology Forum, India.17 Delayed cord • CPAP should be preferred over high flow nasal
clamping and skin-to-skin contact can be practiced. cannulas (HFNC). Limited data from adults suggest
Following key aspects must be kept in mind during that there is possibly a significant dispersion of exhaled
resuscitation: air with HFNC.19
• During initial steps: Routine neonatal care and the Location of care and breastfeeding
initial steps of neonatal resuscitation are unlikely to
There is some ambiguity around neonatal infection
be aerosol generating, however, suction of the airways
risk during postnatal period and care practices vary for
is an aerosol generating procedure and should not be
newborns born to mothers with COVID-19. The possibility
performed routinely for clear or meconium-stained
of the vertical transmission of SARS- CoV-2 through breast
amniotic fluid.
milk could not be categorically confirmed. Presently, only
• During endotracheal intubation and medications limited data on SARS-CoV-2 excretion in breast milk are
(Endotracheal intubation and instillation of available. Chen et al., reported that all breast milk samples
medications, such as surfactant or epinephrine, are from 9 mothers with COVID-19 pneumonia were negative.8
aerosol generating procedures): Intravenous
administration of medicines via umbilical venous Recommendations on these areas from several
catheterization is rather preferred. national and international organizations are summarized
in Table II. WHO supports skin-to-skin care, rooming-in
• Transport to NICU: Closed incubator transfer should and breastfeeding for infants born to mothers with
be used to transfer newborns to neonatal intensive care COVID-19.20 The Royal College of Paediatrics and Child
when available. Health from United Kingdom supports rooming-in and
Management in NICU breastfeeding with appropriate infection prevention
measures for these infants, unless mothers are too ill.21
In the NICU, the baby should be cared for in an The American Academy of Pediatrics (AAP) suggests
incubator in a single room preferably with the potential separation of the COVID-19 positive mother and her infant
for negative room pressure. If this is not available or not when possible and use of expressed breast milk.15 The
possible, newborns should be maintained in a closed Centers for Disease Control and Prevention (CDC) suggest
incubator at least 6 feet apart. These areas should not be a shared-decision making between family and clinical team
part of the central air-conditioning. If room is air- with regards to location of care as well as breastfeeding.22
conditioned, ensure 12 air changes/ hour and filtering of The Indian team (FOGSI, NNF and IAP) recommends
exhaust air.14In NICU, doctors and nurses have to wear rooming in and breastfeeding with strict precautionary
PPE as mentioned above. measures.14
In the NICU, following aspects must be kept in mind
There are problems with separation approach, as
while providing respiratory care to newborns:
separation limits opportunities for parent teaching, disrupts
• During manual ventilation, bacterial/viral filters could breastfeeding and may have negative impacts on mother-

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Indian Journal of Practical Pediatrics 2020;22(2) : 177

Table II. National and international organizations guidance - Newborn care location and
breastfeeding with COVID-19 15
Organization Location of newborn care Breastfeeding
20
WHO Rooming-in with mother Breastfeeding
AAP15 Separation Expressed Breast milk
CDC22 Case to case decision Case to case decision
21
RCPCH, UK Rooming-in with mother Breastfeeding
FOGSI/NNF/IAP, India14 Rooming-in with mother Breastfeeding

newborn bonding. Rooming-in during hospitalization helps outcomes. For well newborns, rooming in with mother and
mother and family to learn infection prevention practices. breastfeeding are advocated with adequate safety
Finally, with the available current evidence, benefits of precautions. For unwell newborns, those who require
breastfeeding outweigh the risks of passing infection from intubation and ventilation, it is critical to consistently
mother to infant. Nevertheless, specific precautions have implement safe respiratory practices including proper
to be taken, such as wearing a mask during breastfeeding isolation, ideal PPE and the use of viral filters to the
and observing meticulous hand hygiene. expiratory limbs of any respiratory device if available.
Finally, current recommendations on the management of
Specific treatment COVID-19 positive mothers and their newborn infants are
Specific anti-COVID-19 treatment like antivirals or based on limited data, demanding continuous and
chloroquine/hydroxychloroquine is not recommended in comprehensive updates.
symptomatic newborns. Use of adjunctive therapy such as Points to Remember
systemic corticosteroids, intravenous immunoglobulin and
convalescent plasma is also not recommended in • Current evidence is inconclusive about vertical
symptomatic newborns with suspected or confirmed transmission of SARS-CoV-2 from mothers with
COVID-19.14 Only supportive care is needed, as per the COVID-19 to their newborns.
problem identified.
• Majority of newborns tested positive for
Discharge SARS-CoV-2, are asymptomatic or have mild disease.
However, their immature immune system makes
Stable newborns, tested negative for COVID-19, can them vulnerable to serious respiratory viral
be discharged based on the center’s normal criteria with infections.
mother or care taker. Asymptomatic newborns tested
• Airborne, droplet and contact precautions should be
positive for COVID-19, may also be discharged home with
followed when attending deliveries and in all
mother or care taker (if mother is unwell) with appropriate
aerosol-generating procedures like suction and
precautions and plans for frequent outpatient follow-up
endotracheal intubation.
contacts till 14 days after birth. Specific guidance regarding
use of masks, gloves and hand hygiene should be provided • Mothers with COVID-19 can breastfeed their
to all caretakers. In mild to moderate respiratory illness, newborn baby, as SARS-CoV-2 has not been detected
they can be discharged as soon as they are well for 3 days, in breast milk to date.
without waiting for a negative COVID-19 test. However,
• Infants born to mothers with COVID-19 should be
in severe illness, it is prudent to wait for a single negative
tested for SARS-CoV-2 at birth or as soon as detection
COVID-19 test after resolution of symptoms, prior to
of contact with COVID-19 positive person. Repeat
discharge.
testing may be needed, if the baby develops symptoms
Conclusion within 14 days of contact or after delivery.
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The proportion of newborns with the COVID-19 is
extremely low when compared to adults. Besides, neonatal 1. WHO. Situation Report. https://http://www.who.int/
COVID-19 appears to be acquired postnatally rather than emergencies/diseases/novel-coronavirus-2019/situation-
through vertical transmission and associated with good reports. 2020 accessed on 16th May, 2020.
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2. Guidelines on preventive measures to contain spread of 12. Sinelli MT, Paterlini G, Citterio M, Di Marco A, Fedeli T,
COVID-19 in workplace settings. CjPMOHFW. https:// Ventura ML. Early Neonatal SARS-CoV-2 infection
http://www.mohfw.gov.in. 2020. Epub. 16th May, 2020. manifesting with hypoxemia requiring respiratory support.
Accessed 17th May, 2020. Pediatrics. 4th May, 2020. PubMed PMID: 32366612.
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Epidemiological and clinical characteristics of 99 cases Valdez LM, La Rosa M. Severe COVID-19 during
of 2019 novel coronavirus pneumonia in Wuhan, China: pregnancy and possible vertical transmission. American
a descriptive study. Lancet. 2020 Feb 15;395(10223): journal of perinatology. 18th Apr, 2020. PubMed PMID:
507-513. PubMed PMID: 32007143. Pubmed Central 32305046.
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14. Chawla D, Chirla D, Dalwai S, Deorari AK, Ganatra A,
4. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical Gandhi A, et al. Perinatal-Neonatal Management of
features of patients infected with 2019 novel coronavirus COVID-19 Infection - Guidelines of the Federation of
in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497- Obstetric and Gynecological Societies of India (FOGSI),
506. PubMed PMID: 31986264. Pubmed Central PMCID: National Neonatology Forum of India (NNF) and
7159299. Indian Academy of Pediatrics (IAP). Indian pediatrics.
5. Yang P, Wang X, Liu P, Wei C, He B, Zheng J, et al. Clinical 1st Apr, 2020. PubMed PMID: 32238615.
characteristics and risk assessment of newborns born to
15. AAP. https://downloads.aap.org/AAP/PDF/COVID%
mothers with COVID-19. Journal of clinical virology: the
2019%20Initial%20Newborn%20Guidance.pdf. 2020.
official publication of the Pan American Society for
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Clinical Virology. 2020 Apr 10;127:104356. PubMed
PMID: 32302955. Pubmed Central PMCID: 7194834. 16. ACOG. https://http://www.acog.org/clinical-information/
6. Fang F, Luo XP. [Facing the pandemic of 2019 novel physician-faqs/covid-19-faqs-for-ob-gyns-obstetrics.
coronavirus infections: the pediatric perspectives]. ACOG. 2020 Published 29th April 2020. Epub Accessed
Zhonghuaerkezazhi = CJP. 2020 Feb 2;58(2):81-85. 17th May 2020.
PubMed PMID: 32102140. 17. Ramji S, Bhat S, Chellani H, Dutta S, Thakre R, Bhatia B
7. Rawat M, Chandrasekharan P, Hicar MD, D et al. Neonatal Resuscitation: India, Text Book 3rd Edition
Lakshminrusimha S. COVID-19 in Newborns and Infants- 2018.
Low Risk of Severe Disease: Silver Lining or Dark Cloud? 18. Chan MTV, Chow BK, Lo T, Ko FW, Ng SS, Gin T, et al.
American journal of perinatology. 7th May, 2020. PubMed Exhaled air dispersion during bag-mask ventilation and
PMID: 32380565. sputum suctioning - Implications for infection control.
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Clinical characteristics and intrauterine vertical 29317750. Pubmed Central PMCID: 5760517.
transmission potential of COVID-19 infection in nine
19. Hui DS, Chow B K, Chu L, Ng S S, Sik-To Lai, Gin T,
pregnant women: a retrospective review of medical records.
et al. Exhaled air dispersion and removal is influenced by
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isolation room size and ventilation settings during oxygen
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delivery via nasal cannula. Respirology. 2011;06(16):
9. Zhu H, Wang L, Fang C, Peng S, Zhang L, Chang G, et al. 1005-1013.
Clinical analysis of 10 neonates born to mothers with
2019-nCoV pneumonia. Translational pediatrics. 2020 20. WHO. https://http://www.who.int/emergencies/diseases/
Feb;9(1):51-60. PubMed PMID: 32154135. Pubmed novel-coronavirus-2019/question-and-answers-hub/q-a-
Central PMCID: 7036645. detail/q-a-on-covid-19-and-breastfeeding. 2020. 7th May
2020. Epub Accessed May 18th 2020.
10. Shalish W, Lakshminrusimha S, Manzoni P, Keszler M,
Sant’Anna GM. COVID-19 and Neonatal Respiratory 21. RCPCH. https://http://www.rcpch.ac.uk/resources/covid-
Care: Current Evidence and Practical Approach. American 19-guidance-neonatal-settings-breastfeeding-by-covid-19-
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32359226. Epub accessed on 18th May 2020.
11. Elshafeey F, Magdi R, Hindi N, Elshebiny M, Farrag N, 22. CDC. Care for breast feeding woman. https://http://
Mahdy S, et al. A systematic scoping review of www.cdc.gov/coronavirus/2019-ncov/hcp/care-for-
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Indian Journal of Practical Pediatrics 2020;22(2) : 179

COVID - 19

COVID-19 : PREVENTION AND 6 feet is one of the most important steps in preventing
EDUCATION spread of the virus. The following steps will help an
individual in preventing spread or minimizing contact with
*Sanjay Srirampur SARS CoV-2.
**Pritesh Nagar
1. Wash your hands frequently with soap and water
Abstract: The novel coronavirus 2019 pandemic has for 20 seconds especially after coming back from a
caused an unprecedented global catastrophe. At present public place or after coughing, sneezing or blowing
there is no known cure, drug or treatment for this disease. your nose. If soap and water is not available, then using
Personal hygiene, social distancing, hygienic practices and hand sanitizer with minimum 60% alcohol
care of the infected persons (asymptomatic/ mild concentration is recommended. Avoid unnecessary
symptomatic) are the only preventive measures we have touching of nose, mouth or eyes.
at present. Usefulness of hydroxychloroquine as a
preventor drug is yet to be proved. At the time of writing, 2. Maintain social distancing in public places and from
eight vaccines have reached clinical stage of trials and household members who are sick.
are being evaluated across the world. In the most optimistic 3. Avoid crowded places and gatherings - this is of
timeline that we can anticipate, it will not be less than a paramount importance.
year before any of the vaccines will be available for public
4. Cover your nose and mouth with cloth cover
use. It is also very important that all routine immunisation
(cloth mask or hand kerchief) when in public or going
practices be continued.
out for daily errands. Follow cough etiquette.
Keywords: Novel coronavirus, SARS-CoV-2, At present, use of medical masks medical masks (also
Hydroxychloroquine, Coronavirus vaccine. known as surgical masks) is not recommended for
general public.
From the time this pandemic has struck across the
globe, it has been a catastrophe for almost all nations. 5. Cleaning and disinfecting frequently touched surfaces
There is no definitive treatment or vaccine available at like door knobs, light switches, mobile phones, tablets,
present. Hence movement restriction, general awareness, laptops, table surface etc. is recommended.
social distancing and measures to improve personal hygiene Any household level disinfectant can be used. A recent
will go a long way in mitigating the spread of this disease. article recommended the use of 70% isopropyl alcohol
The preventive aspects can be considered at the level of an or Clorox wipes for disinfection of mobile phones.
individual, community as a whole and institutions - be it When such a solution is used for disinfection, it is
school or hospital or a workplace. preferable that the mobile phone is in switched off
mode.2
Prevention at individual level1 Use of masks and gloves by public1,3,4,5
Novel Corona virus - SARS-CoV 2 spreads from It is known that the novel coronavirus can be
person to person by means of respiratory droplets and transmitted from asymptomatic carriers as well as
contaminated fomites. The virus is highly infectious and presymptomatic patients. In the light of this evidence, it is
current evidence suggests that it spreads more readily than recommended that people should use cloth based coverings
influenza virus, but not as much as measles. or masks when they go out in public places. The intention
Maintaining good physical distance, preferably more than of cloth based covering is to protect people around the
* Head of Department of Pediatrics individual. However, the use of such a mask should not
** Consultant and Pediatric Intensivist, give a false sense of security leading one to stray away
Aditya Super Speciality Hospital, Hyderabad from social distancing. These masks can be washed with
email : priteshnagar@gmail.com soap and water and reused. Due to shortage, medical masks
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Indian Journal of Practical Pediatrics 2020;22(2) : 180

and respirators are not recommended to be used by general with gloves. It is to be noted that the gloves used during
public. In the following conditions triple layer surgical any of these procedures as mentioned above should be
mask may be used:3 discarded in a sterile manner as discussed before.
If reusable gloves are being used, then they should be
1.When a person develops respiratory symptoms cleaned and disinfected with 1% hyphochlorite after every
2.When visiting a healthcare facility use.
3.When you are caring for someone who is sick at home Prevention at schools6
4.Close contacts of suspected cases Today’s students are tomorrow’s global citizens and
If used properly, a surgical mask will be protective hence, arming them with the right knowledge about
for 8 hours, unless it gets wet. The mask should be discarded COVID-19 is going to decrease their anxiety and fear about
after use by disinfecting with 5% bleach or 1% hypochlorite the disease. It will also help them to cope up with the
and then burnt or by deep burial.3 The routine use of gloves pandemic and decrease the stigmatization of sick amongst
is also not recommended except when caring for a sick teachers and fellow students. Students armed with the right
patient at home or non-healthcare based setting. tools of knowledge will help a society in fighting against
the disease and also serve to pursue preventive measures
Cleaning and disinfection at home1 at their own homes..
Novel coronavirus is transmitted by respiratory In the event of an extremely high community based
droplets more readily as compared to fomites. So, apart transmission, schools are likely to be closed down till the
from precautions against droplets, cleaning and disinfection situation ensures safety of students. The discussion below
of contaminated surfaces will also decrease the pertains to a situation wherein the schools are eventually
transmission of virus. Cleaning, basically means removal going to open. The World Health Organization and
of the dirt impurities and germs from a surface. It does not UNICEF have released a joint document in March 2020
kill the microbes. On the other hand disinfection refers to addressing issues related to prevention of spread of
the process of killing the microbiological organisms. COVID-19 in schools.6 The detailed document is available
Usually disinfection is a process which should be followed on the WHO and UNICEF websites. There is a checklist
after cleaning. Frequently touched surface in the household in this document which the schools can implement to make
environment can be cleaned and disinfected by sure that they are safe. Here is a brief summary of the
commercially available products. 1% hypochlorite solution recommendations.
is an excellent disinfecting agent, if the surface is
compatible. Following manufacturer recommendations and 1. All the personal hygiene, social distancing, cleaning
the compatibility of such a procedure with the surface and disinfecting principles mentioned above need to
should be kept in mind. Use of gloves, mask if required be followed at school very strictly.
and good ventilation is needed during the process of 2. Regular hand washing and sanitisation should be
disinfection. Electronic devices can be disinfected by 70% encouraged and implemented by students and staff
isopropyl alcohol based solutions or wipes. alike. Cleaning and disinfection of the school campus,
Clothes can be laundered as routine or as per class rooms, cafeteria, office and other frequently
manufacturer recommendations. Use of warm or hot water touched surfaces should be done on a regular basis -
is preferable. Use of gloves is preferable when handling at least once a day. The managements of schools
laundry which is dirty or from an infected person. should ensure that the above required facilities,
We should also try to avoid shaking dirty laundry because equipment and supplies are adequate at all times.
that may generate aerosols. Clothes from a sick person can 3. Social distancing in school maybe practiced by
be washed along with routine laundry. staggering the start and the end of the school working
If there is a sick person at home, then he should be hours, avoiding any activity which will involve a
cared for in a separate room isolating from everybody else gathering, trying to distance the classroom seating
at home. It is preferable that the washroom used by the areas by one meter and teaching students to avoid
sick person should be separate. If separate washroom is unnecessary touching.
not feasible, then common washroom should be cleaned 4. Sick students and staff should not attend school.
and disinfected after each use. All the food, linen and other The school should have emergency contact numbers
material connected to the sick person should be handled of the caretakers of children as well as the local health
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Indian Journal of Practical Pediatrics 2020;22(2) : 181

authority. This will help in formulating an emergency 3. Caregiver should be available 24/7 and there should
plan in case someone falls sick at school. be smooth and convenient source of communication
Monitoring the pattern of school absenteeism due to with the healthcare system at any given point of time.
respiratory illness can help the local authorities in 4. The caregivers and close contacts will be on
tracking cases. hydroxychloroquine prophylaxis as per
5. In the unlikely event of difficulty in reopening the recommendations of Indian Council of Medical
schools, online classes and e-learning should be Research (ICMR).
encouraged. 5. The patient will regularly monitor his health and
Prevention at workplaces7 update the status to district surveillance officer.
6. The patient will download “Arogya Setu” app which
The principles of hand hygiene, social distancing, will remain active via internet and bluetooth at all
cough etiquette, regular cleaning and disinfecting of the given times.
environment have all been discussed earlier and apply in a
7. The patient has to give an undertaking as per Annexure
similar manner to a workplace. Hand hygiene can be
I in the guidelines. He is liable for legal action if he
promoted by availability of hand sanitizers at all entry and
fails to follow home isolation guidelines.
exit gates in the work environment as well as at multiple
other places where the likelihood of contamination is high. In addition, ANNEXURE II is available which outlines
Posters highlighting these aspects can be obtained from the precautions the caregiver needs to take at home.
WHO website and pasted across the workplace to promote The caregiver has to be explained the important warning
such activities. Employees should be educated about the signs for immediate consultation to the hospital.
disease, recognition of early symptoms and should be Home isolation is for a period of 17 days after the onset of
instructed to stay at home if they are unwell. Gatherings symptoms, provided the patient is afebrile for 10 days.
and meetings should be avoided as far as possible. Use of The following is a summary from Annexure II
teleconference should be encouraged to maintain social
distancing. If a meeting is mandatory, then all possible 1. The patient should stay in a separate room away from
precautions should be undertaken. If feasible, social all other family members. It is preferable to have a
distancing should be maintained even during such separate washroom for the patient. He should wear a
meetings. Hand hygiene and respiratory hygiene should triple layer surgical mask at all given times. The mask
be maintained during the course of a meeting. Details of should be discarded after 6 hours or whenever it is
all the people coming to work and especially those soiled or wet. The patient should follow hand hygiene,
attending such close gatherings should be available. In the respiratory etiquette and social distancing at all times.
unlikely event of someone falling sick, this information He should maintain nutrition, hydration, monitor
would be of utmost importance to trace all contacts. temperature regularly and inform health authorities if
Contingency plans and protocols for employees falling ill any warning signs develop.
at work should be available in conjunction with local health 2. The caregiver should always wear triple layer surgical
authorities. mask when entering the room of the patient. He should
Precautions during home isolation8 not unnecessarily touch his face, nose or mouth.
The mask of the caregiver and the patient should be
As per the revised guidelines from Government of discarded only after disinfection with 1% hypochlorite
India published on 10th May 2020, it has been solution.
recommended to isolate pre symptomatic or mildly
3. All kinds of contact in the patient area should be done
symptomatic cases at home itself. Precautions at home for
by using gloves. This includes touching of anything
the sick person as well as the caretakers involved are
in the patient room like beddings, clothes, food,
described. The following are the prerequisites for home
surfaces, etc. Frequent disinfection of the patient care
isolation:
area should be done at all times.
1. Diagnosis of COVID positivity in asymptomatic 4. The caregiver will also monitor his as well as other
patients as well as categorising as mild when they have family members’ health which includes temperature
symptoms should have been done by a qualified doctor. monitoring and reporting to health authorities, if there
2. There should be a facility for home isolation for the is a problem. They may need to be tested for COVID
patient and the caregivers or family members. when they become symptomatic
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Indian Journal of Practical Pediatrics 2020;22(2) : 182

Hydroxychloroquine (HCQ) prophylaxis were negative at day 7 and 93% were negative at day 8.
However, clinically relevant outcomes were not described,
The COVID-19 pandemic has put the medical
there was no control group and majority of the patients
community across the globe in a very precarious situation.
had early warning scores less than 4, indicating that they
At the time of writing this article, there is no known
were not that sick, leading to a possible bias in the results.
definitive treatment or prophylaxis available against
Another observational study14 from France in 11 patients
SARS-CoV-2. This has let the scientific community to find
with COVID-19, did not report any benefit in
quickly a safe and effective drug for this virus resulting in
nasopharyngeal clearance of the virus even after 5 - 6 days
a flurry of publications on various possible therapeutic
of treatment. In this study, the cohort of patients were more
options. The antimalarials chloroquine and
sick as compared to the studies by Gautret et al. In a pilot
hydroxychloroquine have shown some promise against the
trial of 30 cases from China15, Jun Chen and colleagues
virus in laboratory studies9. In fact, according to a recent
did not find any difference in the viral clearance in the
report , there is no evidence of in vitro viral activity of
HCQ treated group as compared to the control group.
HCQ.10 The published data available so far do not include
However, concomitant use of other antiviral drugs was also
any high quality studies and there is hardly any evidence
there in both the groups which could have confounded the
based information about the efficacy of HCQ in
results. HCQ was used in a dose of 400 mg per day in the
prophylaxis. Fig.1 demonstrates the possible mechanism
study. Another Chinese randomised parallel group trial16
of HCQ in SARS-CoV-19 infection.
was conducted in 62 patients, out of which 31 received
Data from Gautret, et al 12 , with 36 patients of HCQ in addition to standard care. Time to clinical recovery,
COVID-19 treated with HCQ and azithromycin revealed defervescence of fever and cough remission were
higher percentage of negative nasal swabs between day significantly lower in the treatment arm. Most of the
3 to day 6 in the treatment group. This study used 600 mg patients had mild to moderate disease and whether these
of HCQ per day for 10 days in the treatment group. The results can be directly extrapolated in sicker patients is not
shortfalls of this study were – a very small number of which clear. In another observational study17 of 1376 patients,
only 8 cases actually had pneumonia, lack of any out of which 811 received HCQ, the investigators did not
randomisation, extremely short observation period, find a benefit in the composite endpoint of decreased risk
inclusion of asymptomatic cases, and lack of data on for intubation or death. However, in this study, the treatment
clinical efficacy. A second study13 from the same author arm had significantly more sick patients at baseline as
had a larger patient cohort (80 cases). Similar to the earlier compared to the control arm. So far, there is no published
data, rapid nasopharyngeal viral clearance was noted-83% data on the effectiveness of HCQ as prophylaxis.

Fig.1. Proposed mechanisms of action of HCQ in a simplified manner. (Action 1 and 2 disrupt
viral infectivity and multiplication. Action 3 and 4 reduce cytokine storm.)11
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Indian Journal of Practical Pediatrics 2020;22(2) : 183

At the time of writing this article, 175 trials on HCQ prophylaxis should not undermine the need for personal
in various combinations as well as monotherapy are going hygiene and other mitigating measures explained above.
on; 50 studies out of these are evaluating the role of HCQ Prophylaxis should not give one, a false sense of security
as prophylaxis.18 Large scale multicentre trials, such as the and is to be taken only under prescription from an
Discovery study (NCT04315948) and the Solidarity study authorised medical authority/doctor. It is not recommended
(EudraCT Number 2020-000982-18), will give us answers for children less than 15 years of age and those with
in due course of time. There is a risk of prolongation of retinopathy or hypersensitivity.
QT interval with HCQ, especially if combined with
Vaccines for COVID-19
azithromycin. The current data, albeit very less and our
historical experience with this drug tell us that the risk is At the time of writing this article there are 102
very small. The National Task Force for COVID-19 vaccines in pre-clinical trials and 8 vaccines in phase 1
constituted by the ICMR19 recommends the use of HCQ as and phase 2 clinical trials.20 Table I lists vaccines that are
prophylaxis against SARS-CoV-2 in high risk groups. in clinical trials. The detailed document can be obtained
This chemoprophylaxis is recommended for: from WHO website.
1. Asymptomatic healthcare workers involved in the care ChAdOx1 nCoV-19 (Vaccine 1 in Table.I): The vaccine
of suspected or confirmed COVID-19 cases. being developed by the University of Oxford’s Jenner
Institute and Oxford Vaccine group in UK (ChAdOx1
2. Asymptomatic household contacts of lab confirmed
nCoV-19) has taken the lead and is currently the forerunner
COVID-19 cases.
amongst the COVID-19 vaccines. Human trials have begun
A loading dose of 400 mg twice on the first day is as of April 2020. Human adenovirus is used in this vaccine.
recommended. The weekly maintenance dose is 400 mg to The genetic material for expression of the spike
be given for 7 weeks in the case of healthcare workers and glycoprotein of novel coronavirus has been inserted into
3 weeks in the case of household contacts. The use of the weakened adenovirus to make this vaccine candidate.

Table I. Candidate vaccine in clinical trials against COVID-1920

S.No. Vaccine Platform Developer Current stage of clinical trials
1 ChAdOx1 nCoV-19 Non-replicating viral University of Oxford Phase 1/2 NCT04324606
vendor
2 Adenovirus Type 5 Non-replicating viral CanSino Biological Phase 2 ChiCRT2000031781
vector recombinant vendor Inc./Beijing Institute Phase 1 CHiCTR2000030906
vaccine of Bioechnology
3 LNP encapsulated RNA based vaccine Moderna/NIAID Phase 2 (IND accepted)
mRNA-1273 Phase 1 NCT04283461
4 Inactivated vero cell Inactivated vaccine Wuhan Institute of Phase 1/2 ChiCTR2000031809
vaccine Biological Products/
Sinopharm
5 Inactivated vero cell Inactivated vaccine Beijing Institute of Phase 1/2 ChiCTR2000032459
vaccine Biological Products/
Sinopharm
6 Inactivated coronavirus Inactivated vaccine Sinovac Phase 1/2 NCT04352608
vaccine + Alum
7 BNT16a1, BNT162b1, RNA based vaccines BioNTech/Fosun Phase 1/2 2020-001038-36
BNT162b2, BNT162c2 Pharma/Pfizer NCT04368728
8 DNA plasmid vaccine DNA based vaccine Inovio Phase 1 NCT04336410
with electroporation pharmaceuticals
(INO-4800)
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Indian Journal of Practical Pediatrics 2020;22(2) : 184

As of date, 1090 participants aged 18-55 years have been Inactivated coronavirus vaccine with alum (Vaccine 6
planned to be enrolled in the clinical trial which will utilise in Table. I): The parent company manufacturing the
quadrivalent meningococcal vaccine in the control group. inactivated corona virus vaccine is doing its own
The vaccine will be studied in a single as well as two dose phase 1/2 randomised double blind placebo controlled trial.
schedules. Efficacy of the vaccine as well as occurrence Study is enrolling adults aged 18-59 years to receive 2 doses
of serious adverse events are the primary outcomes of this of the vaccine or a placebo. The vaccine will be studied at
study. Serum Institute of India plans to produce 60 million 2 different inoculation doses of 600 SU or 1200 SU.
doses of this vaccine. Astra Zeneca has tied up with the 144 subjects are expected to be enrolled for phase 1 and
University for production and global distribution of the 600 subjects will be enrolled in phase 2. The estimated
vaccine. The preliminary completion date and data date of completion is expected to be December 2020.
collection is expected to be completed by May 2021.
BNT162a1, BNT162b1, BNT162b2 & BNT162c2 RNA
Recombinant adenovirus vaccine (Vaccine 2 in Table I): based vaccine candidates (Vaccine 7 in Table. I): This
This vaccine has been registered for a phase 2 trial on the phase 1/2 randomized, placebo controlled and observer
Chinese clinical trials registry. It has been proposed to use blind trial is being conducted by Biontech and Pfizer.
two different inoculation doses of the vaccine in the trial One of the four vaccines will be given in a 1 or 2 dose
and a placebo in control group. 250 subjects will be enrolled schedule. The control group will receive a placebo vaccine.
in medium dose group, 125 in low dose group and 125 in The vaccine will be evaluated at 3 different doses in
placebo. Trial details and completion of data collection is 7600 participants aged 18 – 85 years. It is expected to be
expected by January 2021. completed by March 2023.
INO 4800 (Vaccine 8 in Table. I): This is a one of a kind
LNP encapsulated mRNA-1273 vaccine (Vaccine 3 in
DNA plasmid based vaccine presently being evaluated in
Table.I): This is a novel lipid nanoparticle (LNP)-
a phase 1 trial in 40 subjects. The vaccine is administered
encapsulated mRNA vaccine that encodes for a prefusion
intradermally on day 0 and day 28. Electroporation is a
stabilized form of the spike protein of SARS-CoV-2. It is
technique where permeability of cells is increased to
being developed by Kaiser Permanente Washington Health
enhance the uptake of DNA. This DNA then leads to
Research Institute (KPWHRI) in Seattle, and is funded by
transcription inside the cells, causing an immune reaction
the National Institute of Allergy and Infectious Diseases
which will generate protective immunity against novel
(NIAID). The phase 1 trial is evaluating the safety and
coronavirus. CELLECTRA is a patented hand held device
immunogenicity of the vaccine in 105 subjects.
made by Inovio Pharmaceuticals which helps in
The participants aged 18 years and older will receive
electroporation following vaccination. The initial trial is
2 doses, 28 days apart; in 1 of the 3 concentrations - 25mcg,
expected to be completed by April 2021.
100mcg or 250mcg. It has also received an FDA approval
for phase 2 trial. Phase 2 will enrol 600 subjects with Routine vaccination in COVID-19 pandemic21
3 groups receiving placebo or 50mcg vaccine or 250mcg
vaccine in adults 18 years and older. The primary Immunisation has been recognised as a core essential
completion of phase 1 is expected to be around September healthcare service, and needs to be continued in a safe
2021. manner even during the pandemic. A healthy child
undergoing immunisation does not have any additional risk
Inactivated coronavirus vero cell vaccine (Vaccine 4 and due to the pandemic. On the other hand, immunisation is
5 in Table. I): Inactivated vero cell based novel coronavirus going to protect the child against vaccine preventable
vaccine is being evaluated by Wuhan Institute of Biological communicable diseases. Immunisation should be done in
Products and Beijing Institute of Biological Products into separate or segregated OPDs at all levels, be it a private
separate phase 1 / 2 trials. The vaccine manufactured by clinic, nursing home or a multi-speciality hospital. The birth
Sinovac Research and Development Company will be dose of vaccines needs to be given before discharge from
inoculated in 2 doses, 28 days apart. The Wuhan trial will the hospital. All the vaccines in the first year of life are a
enrol subjects more than 6 years of age where as the Beijing priority and should not be postponed. Influenza and
trial will enrol subjects from the age of 3 years onwards. varicella vaccines also need to be given. Other vaccines
The initial data is expected 6 months after the completion and boosters may be postponed only if logistics do not
of the trial. At the time of writing, no other timelines are permit. All mass immunisation activities should be
available from the Chinese clinical trial registry. postponed to maintain social distancing measures.

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Indian Journal of Practical Pediatrics 2020;22(2) : 185

Points to Remember 6. Interim guidance for COVID-19 prevention and control

in schools [Internet]. UNICEF. 2020 [cited 2020May11].
• Individual level prevention of COVID-19 by general Available from: https://www.unicef.org/reports/key-
public depends on social distancing, frequent hand messages-and-actions-coronavirus-disease-covid-19-
washing, wearing of cloth masks and periodic prevention-and-control-schools. Accessed on 11th May
decontamination of surfaces. 2020.
7. Getting your workplace ready for COVID-19: How
• Schools, when they start functioning and work places COVID-19 spreads, 19th March 2020 [Internet]. World
should constantly educate the students and employees Health Organization; 2020 [cited 2020 May11]. Available
respectively, on maintaining adequate distance, from: https://apps.who.int/iris/handle/10665/331584.
avoiding crowding and hand hygiene and make it Accessed on 11th May 2020.
possible by provision of facilities. They must also 8. Revised guidelines for Home Isolation of very mild/pre-
encourage to report early if any symptoms develop symptomatic COVID-19 cases [Internet]. Ministry of
in them. Health and Family Welfare, Government of India; 2020
[cited 2020 May 13]. Available from:https://
• The patient and care giver must strictly follow all www.mohfw.gov.in/pdf/Revised guidelines for home
the norms laid down for home isolation of pre isolation of very mild presymptomatic COVID-19 cases
symptomatic or mildly symptomatic cases. 10th May 2020.pdf. Accessed on 13th May 2020.
9. Liu J, Cao R, Xu M, et al. Hydroxychloroquine, a less
• The role of hydroxychloroquine in prevention and
toxic derivative of chloroquine, is effective in inhibiting
treatment await robust published results. Till then, SARS-CoV-2 infection in vitro. Cell Discov;
the recommendations of ICMR are to be followed 2020;6:16.Doi: https://doi.org/10.1038/s41421-020-
for chemoprophylaxis with hydroxychloroquine by 0156-0.
high risk contacts only under prescription from an 10. Owens B. Excitement around hydroxychloroquine for
authorised medical authority/doctor. treating COVID-19 causes challenges for rheumatology.
The Lancet; 2020; 2:e257. Doi: 10.1016/S2665-
• There are eight RNA or DNA based inactivated
9913(20)30089-8.
vaccines in phase I/II stages of development.
11. Dan Zhou, Sheng-Ming Dai, Qiang Tong, COVID-19.
• Immunization services especially the primary doses A recommendation to examine the effect of
of vaccines should be administered to all the eligible hydroxychloroquine in preventing infection and
children. progression, J Antimicrob Chemother; dkaa114. Doi:
https://doi.org/10.1093/jac/dkaa114.
References 12. Gautret P, lagier JC , Parola P, Hoang VT , Medded L,
Mailhe M et al. Hydroxychloroquine and azithromycin as
1. Coronavirus Disease 2019 (COVID-19) [Internet]. Centers a treatment of COVID-19: results of an open-label non-
for Disease Control and Prevention; [cited 2020 May10]. randomized clinical trial. International journal of
Available from: https://www.cdc.gov/coronavirus/2019- antimicrobial agents, 20th Mar 2020:105949. Doi: 10.1016/
ncov/index.html. Accessed on 10th May 2020. j.ijantimicag.2020.105949.
2. Panigrahi SK, Pathak VK, Kumar MM, Raj U, Priya PK. 13. Gautret P, Lagier JC, Parola P, Hoang VT, Meddeb L,
COVID-19 and mobile phone hygiene in healthcare Sevestre J, et al. Clinical and microbiological effect of a
settings. BMJ Global Health 2020; 5:e002505. combination of hydroxychloroquine and azithromycin in
Doi:10.1136/ bmjgh-2020-002505. 80 COVID-19 patients with at least a six-day follow up:
3. Guidelines on use of masks by public [Internet].Ministry an observational study. Travel Med Infect Dis; 2020;34:
of Health and Family Welfare, Government of India; 2020 101663. Doi: 10.1016/j.tmaid.2020.101663.
[cited 2020May13]. Available from:https://www.mohfw. 14. Molina JM, Delaugerre C, Le Goff J, et al. No evidence of
gov.in/pdf/Useofmaskbypublic.pdf. Accessed May 2020. rapid antiviral clearance or clinical benefit with the
4. Advisory & Manual on use of Homemade Protective Cover combination of hydroxychloroquine and azithromycin in
for Face & Mouth [Internet]. Ministry of Health and Family patients with severe COVID-19 infection. Med Mal Infect
Welfare, Government of India; 2020 [cited 2020 May13]. 2020; 50:382-387. Doi: https://doi.org/10.1016/j.medmal.
Available from:https://www.mohfw.gov.in/pdf/Advisory & 2020.03.006.
Manual on use of Home made Protective Cover for Face 15. Chen J, Liu D, Liu L, Ping L, Qingnian XU , Lu XIA et al.
& Mouth.pdf. Accessed on 13th May 2020. A pilot study of hydroxychloroquine in treatment of patients
5. World Health Organization. (2020). Advice on the use of with common coronavirus disease-19 (COVID-19).
masks in the context of COVID-19: interim guidance, J Zhejiang Univ (Med Sci)2020;49(2):215-219.
6th April 2020. World Health Organization. Doi: 10.3785/j.issn.1008-9292.2020.03.03.
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Indian Journal of Practical Pediatrics 2020;22(2) : 186

16. Chen Z, Hu J, Zhang Z, Jiang S, Han S, Yan D et al. Annexure II

Efficacy of hydroxychloroquine in patients with
COVID-19: results of a randomized clinical trial. medRxiv Instructions for care-givers
2020; published online March 31 st . Doi:10.1101/
2020.03.22. 20040758 (preprint). • Mask: The caregiver should wear a triple layer
medical mask appropriately when in the same room
17. Geleris J, Sun Y, Platt Jonathan et al. Observational study
of hydroxychloroquine in hospitalized patients with with the ill person. Front portion of the mask should
COVID-19. N Engl J Med 7th May 2020. Doi: 10.1056 not be touched or handled during use. If the mask gets
NEJMoa2012410. wet or dirty with secretions, it must be changed
18. COVID 19 NMA [Internet]. [cited 2020 May15]. Available immediately. Discard the mask after use and perform
from: https://covid-nma.com/dataviz/. hand hygiene after disposal of the mask.
19. Advisory on the use of Hydroxychloroquine as prophylaxis • He/she should avoid touching own face, nose or mouth.
for SARS-CoV-2 infection. Ministry of Health and Family
Welfare, Government of India; 2020 [cited 2020 May 15]. • Hand hygiene must be ensured following contact with
Available from: https://www.mohfw.gov.in/pdf/Advisory ill person or his immediate environment.
on the use of Hydroxychloroquin as prophylaxis for SARS • Hand hygiene should also be practiced before and after
CoV2 infection.pdf. Accessed on 15th May 2020.
preparing food, before eating, after using the toilet,
20. Draft landscape off COVID-19 candidate vaccines and whenever hands look dirty. Use soap and water
11th May 2020. World Health Organization; 2020 [cited
for hand washing at least for 40 seconds. Alcohol-
2020 May 15]. Available from: https://www.who.int/who-
documents-detail/draft-landscape-of-covid-19-candidate-
based hand rub can be used, if hands are not visibly
vaccines. Accessed on 15th May 2020. ACVIP Guidelines soiled.
on Immunizations during COVID-19 Pandemic [Internet]. • After using soap and water, use of disposable paper
Advisory Committee on Immunization Practices, Indian towels to dry hands is desirable. If not available, use
Academy of Pediatrics; 2020 [cited 2020 May 16].
dedicated clean cloth towels and replace them when
Available from: https://iapindia.org/pdf/1455-FINAL-
they become wet.
ADVISORY-ACVIP-Guidelines-on-Immunisations-
during-COVID-19-Pandemic-skd.pdf. Accessed on • Exposure to patient: Avoid direct contact with body
16th May 2020. fluids of the patient, particularly oral or respiratory
Annexure I secretions. Use disposable gloves while handling the
patient. Perform hand hygiene before and after
Undertaking on self-isolation removing gloves.
I ………………………… S/W of ……………………, • Avoid exposure to potentially contaminated items in
resident of ………………………………………………. his immediate environment (e.g. avoid sharing
cigarettes, eating utensils, dishes, drinks, used towels
being diagnosed as a confirmed/suspect case of
or bed linen).
COVID-19, do hereby voluntarily undertake to maintain
strict self-isolation at all times for the prescribed period. • Food must be provided to the patient in his room
During this period I shall monitor my health and those • Utensils and dishes used by the patient should be
around me and interact with the assigned surveillance team/ cleaned with soap/detergent and water wearing gloves.
with the call center (1075), in case I suffer from any The utensils and dishes may be re-used. Clean hands
deteriorating symptoms or any of my close family contacts after taking off gloves or handling used items.
develops any symptoms consistent with COVID-19. I have
been explained in detail about the precautions that I need • Use triple layer medical mask and disposable gloves
to follow while I am under self-isolation. while cleaning or handling surfaces, clothing or linen
used by the patient. Perform hand hygiene before and
I am liable to be acted on under the prescribed law for any after removing gloves.
non-adherence to self-isolation protocol.
• The care giver will make sure that the patient follows
Signature ________________________ the prescribed treatment.

Date ________________________ • The care giver and all close contact will self-monitor
their health with daily temperature monitoring and
Contact Number ________________________ report promptly if they develop any symptom

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Indian Journal of Practical Pediatrics 2020;22(2) : 187

suggestive of COVID-19 (fever/cough/difficulty in • Follow respiratory etiquettes all the time.

breathing).
• Hands must be washed often with soap and water for
Instructions for the patient at least 40 seconds or clean with alcohol based
sanitizer.
• Patient should at all times use triple layer medical
mask. Discard mask after 8 hours of use or earlier if • Don’t share personal items with other people.
they become wet or visibly soiled. • Clean surfaces in the room that are touched often
• Mask should be discarded only after disinfecting it (tabletops, door knobs, handles, etc) with
with 1% sodium hypochlorite. 1% hypochlorite solution.
• Patient must stay in the identified room and away from • The patient must strictly follow the physician’s
other people in home, especially elderlies and those instructions and medication advice.
with co-morbid conditions like hypertension, • The patient will self-monitor his/her health with daily
cardiovascular disease, renal disease etc. temperature monitoring and report promptly to the
• Patient must take rest and drink lot of fluids to maintain health authorities, if develops any deterioration of
adequate hydration. symptom.

CLIPPINGS

Soluble urokinase plasminogen activator receptor (suPAR) predicts who needs higher levels of respiratory
support.
Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker for activation of the inflammatory
and immune systems. Blood levels of suPAR are positively correlated with pro-inflammatory biomarkers, such
as tumor necrosis factor-α, leukocyte counts, and C-reactive protein.
Since March 1, 2020, 57 patients with at least two signs of the systemic inflammatory response syndrome with
community-acquired pneumonia and molecular documentation of SARS-CoV-2 in respiratory secretions were
enrolled.
Patients were followed up daily for 14 days; the development of Severe respiratory failure (SRF) defined as
PO2/FiO2 ratio less than 150 requiring mechanical ventilation (MV) or continuous positive airway pressure
treatment (CPAP) was recorded. suPAR was measured by an enzyme immunoassay in duplicate.
The study endpoint was the prognostic performance of suPAR admission levels for the development of SRF
within 14 days.
Admission levels of suPAR were significantly greater among patients who eventually developed SRF. Receiver
operator characteristics curve analysis identified levels > 6 ng/ml as the best predictor for SRF. At that cutoff
point, the sensitivity, specificity, positive predictive value and negative predictive value for the prediction of
SRF was 85.7%, 91.7%, 85.7% and 91.7%, respectively.
The time to SRF was much shorter among patients with suPAR > 6 ng/ml.
An analysis of the TRIAGE III trial in 4420 patients admitted at the ED in Denmark revealed that suPAR ranged
between 2.6 and 4.7 ng/ml in 30-day survivors and between 6.7 and 11.8 ng/ml in 30-day nonsurvivors.
Findings suggest that suPAR may early trace patients who need intensified management probably in need of
anti-inflammatory treatment.
Rovina N, Akinosoglou K , Eugen-Olsen J, Hayek S, Reiser J, Evangelos J. Soluble urokinase plasminogen
activator receptor (suPAR) as an early predictor of severe respiratory failure in patients with COVID-19
pneumonia. Critical Care 2020; 24:187. https://doi.org/10.1186/s13054-020-02897-4.

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COVID - 19

THE ROLE OF PEDIATRICIAN DURING with recommendations for private practitioners to resume
THE PANDEMIC their practice keeping in mind the ‘the do’s and don’ts’.
Guidelines for immunization services were issued. For safe
*Ramachandran P and successful patient care, pediatrician has to develop the
**Sunil Srinivasan skills of effective leadership, communication, teamwork
and guidance. As the situation is dynamic and evolving,
Abstract : With the emergence of the corona virus disease
the recommendations nationally and regionally are likely
2019 pandemic, many containment measures were imposed
to be updated and the practitioner has to keep abreast of
including lockdowns. As the lockdown is gradually eased
them. Effective infection control protocols in the outpatient
out, there are recommendations put in place by both the
setting can prevent unnecessary exposures to COVID
government as well as international and national
among patients, healthcare personnel and visitors at the
professional bodies for restarting and continuing of child
facility. In this article, a practical approach to outpatient
health care delivery in a safe manner. The pediatrician
care of children in the post-lockdown period is summarized.
has to put in place new norms in terms of infection
prevention and control practices, training and motivation State of pandemic
of fellow healthcare workers, immunization practices,
telemedicine and selfcare to render continuous quality As on third week of May 2020, the infection is
healthcare and to mitigate risk of infection to all including continuing in many parts of our country with large numbers
oneself and to the patients. affected in many metropolitan cities like Mumbai, Delhi,
Chennai, Ahmedabad and Kolkata. The important fact
Keywords: Post lockdown, Preparation, Infection relevant to practicing pediatricians is that majority of the
prevention and control, Patient examination, infected people are asymptomatic or mildly symptomatic
Immunization. and children (0-18 years) form a very small percentage of
infected, ranging 1.2% (Italy) to 10% (Iceland) of total
The emergence of corona virus disease 2019
cases.1 In Tamilnadu, as on fourth week of May, children
(COVID19) pandemic has left many pediatric and general
less than 12 years constitute 6.18% (1003 out of
practitioners in a quandary. Many small hospitals, private
16,277 persons tested positive) (The Hindu newspaper,
clinics and consultation rooms were initially closed
Chennai Edition, May 25, 2020).
following government guidelines on lockdown. Patients
were persuaded to contact their doctors by phone and avoid Preparation
attending any health care facility for minor problems.
For serious illnesses they were referred to bigger It has been said time and again by many experts that
institutions, government or private. Immunization services the virus is here to stay. Hence, the changes in our practice
were kept in abeyance. In April 2020, the state Governments should stay with us and become the ‘new normal’.
and professional bodies like Indian Medical Association We need to prepare ourselves and adopt new strategies.
(IMA) and Indian Academy of Pediatrics (IAP) came out Financially, we have to make sure that there is adequate
cash flow, in case of quarantine and enough securities, in
* Professor of Pediatrics, case our family members get hospitalized.
Sri Ramachandra Medical College and
Research Institute, Chennai.
The following preparations will help us to resume the
services effectively.
** Consultant Pediatrician,
President 2018, Mental readiness
Indian Academy of Pediatrics, Tamil Nadu and
National Convener 2020, Smart Clinic 2.0, This is probably the most important preparation.
Trichy. The pediatrician should be willing to see his patients and
email: ramachandran.paeds@gmail.com help them and the parents, of course, with proper
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Indian Journal of Practical Pediatrics 2020;22(2) : 189

precautions in place. There is no halfway about it. needs and concerns during this stressful period.
Proper communication with parents and strict observation The financial problems faced by them are much higher
of ‘infection prevention and control (IPC) practices will than those of the doctors who also have to anticipate
mitigate the risk of transmission. reduced earnings in the next few months. The HCWs also
need psychological support and assurance. Besides, they
Knowledge
need upgradation of knowledge and necessary skills related
Keeping abreast of the disease from reliable sources to IPC practices. HCWs are infected in much higher
like Indian Academy of Pediatrics (IAP), Indian Council numbers and as per a study in Delhi in April 2020; one in
of Medical Research, Ministry of Health and Family every 15 COVID cases is a HCW.3 Clear instructions
Welfare, Government of India (MOHFW,GOI), Centre for regarding their role and personal protection must be
Disease Control (CDC) and World Health Organization emphasized and periodically reinforced. Continuous
(WHO) is necessary. Internet based learning has become supervision is needed so that they may not fault in wearing
the new norm and we have to embrace it and apply to our appropriate personal protective equipment (PPE) and
practice judiciously. IAP website (www.iapindia.org) has maintaining all IPC practices. These general principles are
provided important GOI notifications and guidelines.2 also applicable to the out-patient settings of bigger units
and teaching institutions.
Government regulations and advisory
Preparation of team members
As the infection due to severe acute respiratory distress
syndrome corona virus-2 (SARS-CoV-2) is just 5 months • Personal protection gear: Ensure adequate availability
old and been having a significant impact in India only since and knowledge of use.
March 2020, the MOHFW, GOI and respective state • Instructions to refrain from touching the eyes, nose,
governments have been coming out with regulations and and mouth with potentially contaminated gloved or
advisory periodically based on the available data and ungloved hands.
knowledge. As the situation is dynamic, so are the
regulations. It is better for the clinician to download the • Rotation of duty hours with adequate intervals.
government recommendations in a dedicated file and refer • Instructions on interaction with parents:
to them when required. There were many strict restrictive
measures during the initial periods under Epidemic disease - Safe distance while questioning
Act 1897 and the Disaster Management Act 2005, which - Not to touch any documents or old records
had a bearing on the function of health care workers
- Making sure that the attendant and older children
(HCWs) and health facilities. These have been partially
above 2 years are wearing mask
relaxed taking into account the ground realities, need for
accessible health care and the likely trajectory of the - Cashless payment or handling cash with gloves
pandemic. and collection in separate bags to be handled after
72 hours.
Cross-talking
- Avoid weighing unless absolutely necessary and
Despite the guidelines and the scientific principles, cleaning surface of weighing machine after each
maximum practical solutions are likely to come from our use
professional colleagues who are also in the same boat.
Exchange of ideas and innovative solutions with constant - Minimal waiting time and maximal distance
revision is a way-out to overcome unique problems. between families
No two practices or clinics are the same. Each practitioner • Psychological: Staff can be demotivated, due to various
has to adopt the good practices according to his situation. conflicting ideas in the social media. Comforting
words and clear explanations will be very helpful.
Manpower training and support for HCWs
Extra incentives during this season will be
Private practitioners barring a few exceptions may just encouraging.
have one or two semi/unskilled persons to help them in Parent and family education
patient management. Their role was confined to cleaning
the premises and regulating the patient entry during Besides the economic and social impact, many parents
consultation. These HCWs are the ones who have stood also face great anxiety about their children’s risk of getting
by them at all times. It is imperative to take care of their the infection in the post-lock down period especially with
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Indian Journal of Practical Pediatrics 2020;22(2) : 190

schools re-opening. An empathetic pediatrician is a great • Adequate distance of minimum of 1 meter on sides,
support for them. Realistic information has to be given to front and back between waiting persons including
the family members regarding the nature of infection spread children should be ensured. Alternate seats can be
and all the possible safe practices to be followed by them barricaded to maintain social distancing.
and the children. Unnecessary fear or panic is to be avoided.
• Health information posters related to
The pediatrician should discuss with them upfront his plans
COVID-19 and prevention can be displayed.
and type of private practice and alternative support.
Though professional charges are allowed for • Playthings, toys, books etc., should be removed.
teleconsultations, discretion can be exercised for individual • Depending on the facilities available, segregate the
patients. The following clear instructions to parents will children coming for immunization and other illnesses
help in IPC practices. in terms of space and if not possible, in time by prior
• Appointments: Scheduled to avoid crowding and appointment.
promote smooth turnover. • If a separate fever clinic is not possible to create,
children with fever/ILI should be given separate time
• Accessibility: Over the phone 24/7 availability of an
and not be allowed to wait with other children brought
experienced staff if possible; otherwise the
for well baby check or immunization.
pediatrician’s availability over phone.
• Ensure adequate ventilation in all places by keeping
• Briefing: What should be brought to clinic (one
the doors and windows open.
change of dress, one water bottle) and what not to
bring (old records, toys, etc). Attendants above 60 Disinfection and cleaning
years to be instructed not to accompany the child.
• Provision of sanitizing hand rub and hand wash
• Payment: Cashless if possible and the methods to do facilities with soap and water is ensured at multiple
so. places.
Hospital/Clinic setting3,4 • Public areas like waiting areas and toilets have to be
disinfected once in 2 hours with 1% hypochlorite
Flow of patients (bleach) or 5% benzalkonium solution.
At entry • Weighing machines and stethoscopes have to be
disinfected after every patient use. (Table I)
• Hand sanitization should be universal for anybody
entering the clinic and a mask if not already worn by Personal protection equipments (PPEs)
them. Children less than 2 years of age are not expected The PPEs are to be used based on the risk profile for HCW.
to wear a mask. Table II gives the basic PPE required.
• All parents and visitors should have Aarogya Setu app
The following points are to be remembered while using
for contact tracing or their address and phone numbers
PPE:
have to be documented.
• Screening questionnaire for fever/ influenza like illness • Standard precautions are to be followed all the time
(ILI) should be administered and temperature checked. • PPEs are not alternative to other important IPC
• Anyone coming with fever or ILI should be directed practices such as hand hygiene, safe distancing and
to a separate ‘Fever clinic’ in all facilities where cough etiquette
children with fever/ILI should be directed to, examined • PPEs are to be disposed as per the IPC regulations
and managed as per the Government order in some
• In practice, N95 masks and face/ eye shields may be
states.5
restricted to fever clinics, suspected and confirmed
• Proper signages should be provided for patients to go COVID wards and aerosol generating procedures such
to designated areas without hassle. as nebulization and sample collection.
Waiting area Many practitioners prefer to use N95 mask also during
well baby and other non-COVID consultations in view
• Schedule consultations appropriately and avoid of significant number of infected asymptomatic
waiting as much as possible persons.
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Indian Journal of Practical Pediatrics 2020;22(2) : 191

Table I. Cleaning different areas of clinic2-4

Area/items/Frequency Item/equipment Process Method
Floor of the clinic / Dust mop/damp mop 3 buckets Sweeping, i) Sweep with dust mop/damp mop
Waiting area- 2 hourly (Plain water, detergent solution Cleaning, ii) Next, mop the area with water and
with water, 1% sodium Daily mopping detergent solution - Then clean the
hypochlorite) mop in plain water and squeeze
iii) Repeat this in the remaining area
iv) Then, mop the whole area again
with 1% hypochlorite solution starting
at the far corner of the room and work
towards the door
Railings, doorknobs, Damp cloth, Detergent solution Clean and wipe - Clean with damp mop
surfaces (reception desk, with water 1% sodium - Wipe with hypochlorite or detergent
doctors table) hypochlorite solution and water
- Every 4 hours
Stethoscope, 70% alcohol based rub/ Clean and wipe Wipe with alcohol based rub/spirit
thermometer (axillary) - spirit swab swab
between every patient

Table II. PPEs for different areas2,3,6,7,8

Setting Risk stratification Recommended PPE Other precautions
Registration/ Mild risk Triple layer mask, Physical distancing at all times
Front desk Latex examination gloves
Doctor Mild risk* Triple layer mask **, Hand sanitization after every patient
Latex examination gloves examination
No aerosol generating procedures such as
nebulization
Nurses Mild risk* Triple layer mask** Minimum distance of one meter needs
Gloves to be maintained.
Pharmacist Mild risk Triple layer mask, Frequent use of hand sanitizer over gloves
Latex examination gloves
* Categorised as moderate risk by IAP; **IAP- N95 mask
MoHFW,GOI7,8 and others - For non COVID setting, mild risk

Video/tele consultations • When scheduling appointments by phone, provide

instructions to persons with or without signs or
This is promoted as much as possible. The recent symptoms of COVID-19 on how to arrive at the clinic,
notification by Government of India clearly spells out the including which entrance to use and the precautions
type, charging of professional fees and the drugs which to take (e.g., how to notify clinic staff and follow triage
can be prescribed.9 procedures)
Consultation planning10 • Make them wait in their vehicle and inform them
through phone when their appointment is due.
• Provide as many tele consultations as possible. • If possible, schedule appointment for any child with
Clear instructions are provided regarding the charges illness at the end of day and complete the well child
for follow-up consultations and new consultations. consultations earlier.
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Indian Journal of Practical Pediatrics 2020;22(2) : 192

• Do not have people waiting at OPD or diagnostic areas;

minimize the waiting time by providing spaced
appointments.
• Discourage walk-in patients.
• Keep the doors of consulting room open so that nobody
needs to touch them while opening or closing.
• Keep a separator or rope to avoid people touching the
registration counter.
• Patients with respiratory symptoms can directly go to
a separate room spacious and airy and sit in the centre
of the room where they cannot touch anything in the
surrounding and they can be quickly examined and
sent.
• Inform all patients, that if they or any close contact
have cough or fever, they should call first and not visit
the clinic/hospital without tele consultation.
Patient examination
• Keep a distance of three feet while taking history
• Avoid throat examination unless absolutely necessary.
• Avoid auscultation as much as possible, auscultate
from back if needed; Blue tooth stethoscope is gaining
more attention during this COVID era. It is a simple
cost effective device to auscultate children safely
during the pandemic period. All it requires is an old
stethoscope with a workable diaphragm, and a blue
tooth device, costing approximately Rs.3000.
Commercial variants are available which are Fig.1. Assembling blue tooth stethoscope
manufactured indigenously, some with artificial
intelligence that filter surrounding noise and can be
shared across iOS and android platforms. A simpler
variant can be designed by the following procedure.
Cut the tubing of the stethoscope about 2 inches from
the chest piece. From the blue tooth device, the mike
can be removed and soldered to the chest piece.
Connecting wires are threaded through the tube and
then connected with the speaker, Fix the blue tooth Fig.2. Cut Fig.3. Steth Fig.4. Bluetooth
speaker securely to the tubing and make sure the steth with opened up to device
diaphragm of the stethoscope is screwed tight. blue tooth show tip of
This blue tooth device is then paired to a mobile which device receiver at
is kept in the examining room. The blue tooth the central
stethoscope is ready for use. (Figs.1,2,3,4). hole

• Either the mother or fully protected HCW, can switch • Viewing old records: Preferably digital, e.g., IAP
on the blue tooth speaker and keep the stethoscope approved software.
over the chest of the child, at various places as
• Prescription: Preferably digital, like IAP approved
indicated by the doctor. The pediatrician can ring up
software.
the paired mobile from any place and use either
headphones or loudspeaker to hear the auscultated • Maintain supply of masks, disinfectant/sanitizer and
sounds. other personal protective equipment.
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• Disinfect all things that one touch us during work: • Prioritize pneumococcal and influenza vaccines to
including computers, keyboards, scanners, door vulnerable groups. Healthcare personnel should be
handles, BP instrument, stethoscope, SpO2 monitor upto date in their age appropriate vaccinations.
with alcohol swab (Table I).
• Typhoid conjugate vaccines may be clubbed with the
• Infant weighing scales can be washed with soap and influenza vaccine at 6 months or MR/MMR at
water. Separate clean paper (news paper) should be 9 months.
used for every baby to prevent risk of hypothermia • Hepatitis A vaccines and HPV vaccines may be
and cross infection. postponed to a later date if logistic issues of transport,
• While the Pediatrician returns back home from clinic, etc., exist.
he should wash feet first, then hands, face, change • Multiple vaccines can be administered in the same
clothes (keep them in separate box for washing), session without fear of any increased adverse effects.
decontaminate all surfaces he may have touched
including car and finally wash hands again with soap • Boosters may be postponed to a later date, if logistic
and water. Mobile can be cleaned with a soft cloth issues of transport, etc. exist.
and 70% alcohol after switching off. Preparing one’s own family to handle COVID
pandemic
• Doctors with cough and fever should opt for self-
quarantine and COVID assessment. • Explanation: The pediatrician has to explain about the
disease to all his family members. Even young children
Immunization11-13
can understand a few aspects of the disease.
General instructions for vaccination clinics • Protection: Hand washing, disinfection, distancing
from elders as needed, physical activity, healthy diet,
1. It is strongly recommended to have exclusive
regular food habits and sleep.
vaccination sessions and exclusive vaccination rooms.
A polyclinic/ nursing home/ hospital should have • Sharing: Information regarding financial situation with
segregated vaccination areas with separate entrance spouse, location of important documents like house
and exit. deeds, cheque books, aadhar card, etc. Telephone
numbers of important contacts like lawyer, auditor,
2. Give vaccinations by appointment only. close family members, as well important passwords
3. Well-baby visits may be combined with to be accessible to spouse.
immunizations. • Contingency plan: If one of the spouses falls ill or has
4. Utilize every healthcare visit for immunization, to be quarantined (a distinct possibility), what should
provided there are no contraindications and the interval the other members of the family be doing, and who
between vaccines are maintained as per published should be responsible. Hospitalization options and
guidelines. insurance to be utilized may be planned.
Points to Remember
5. It is essential that the doctor and supporting staff utilize
adequate PPE. In a vaccination clinic, surgical masks • Be prepared, mentally, physically and financially,
and gloves are necessary along with scrupulous hand to handle this pandemic.
hygiene. • Safety guidelines, personal and personnel protection,
6. All other IPC practices outlined above are to be can never be taken too lightly, even if the rest of the
followed stringently in vaccination sessions too society are not compliant.

Prioritizing vaccines in routine • Give priority to catch up vaccination in the initial

immunization days of resuming practice and designate separate
times and space for handling healthy children.
• Vaccinate newborns in maternity set up, before
• Telemedicine, phone consultation, use of social
discharge with BCG, OPV and Hepatitis B vaccines.
media to communicate our plans, judicious use of
• Prioritize primary vaccination series: DPT, Hep B, Hib, our instruments of practice, planned consultation,
OPV/IPV, rotavirus vaccines, PCV, influenza, varicella and meticulous screening of patients are the new
and MR/MMR. Avoid postponing these vaccines. normal.
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Indian Journal of Practical Pediatrics 2020;22(2) : 194

• Parent and family education goes a long way in the detail/rational-use-of-personal-protective-equipment-for-

smooth handling of our practice. coronavirus-disease-(covid-19)-and-considerations-
during-severe-shortages. Accessed 17th May 2020.
References
7. https://www.mohfw.gov.in/pdf/Guidelinesonrationaluse of
1. Birmingham Health Partners. COVID-19: Research Personal ProtectiveEquipment.pdf. Accessed on
Update Pediatrics. Issue#APR_V3.03 Date: 2nd Apr 2020. 17th May 2020.
www.Birminghamhealthpartners.co.uk. Accessed 16th May 8. Novel Coronavirus Disease 2019 (COVID-19): Additional
2020. guidelines on rational use of Personal Protective Equipment
2. Website: www.iapindia.org. Accesseed 20th May 2020. (setting approach for Health functionaries working in
3. Association of Health care Providers (India) and Public non-COVID areas). Updated on 15 th May 2020.
Health Foundation of India (PFHI) Post Lockdown Lifting: https://www.mohfw.gov.in/pdf/Guidelines on rational use
Resumption of Hospital Services: A Protocol Document. of Personal Protective Equipment.pdf. Accessed 25th May
ahpi.in AHPI_Training_programs.html. Accessed 12th May 2020.
2020. 9. https://www.mohfw.gov.in/pdf/Telemedicine.pdf.
4. https://www.who.int/emergencies/diseases/novel- Accessed 17th May 2020.
coronavirus-2019/technical-guidance/infection- 10. IAP-COVID 19 bulletin. Available at www.iapindia.org.
prevention-and-control). Accessed on 15th May 2020. Accessed on 21st May 2020.
5. G.O. (M) No. 181, Health and Family Welfare Department,
11. Guiding principles for immunisation activities during
Tamilnadu dated 08.04.2020 and Guidelines G.O.(Ms) No.
COVID-19 pandemic, 26th Mar 2020. WHO/2019- nCoV
210, Health and Family Welfare Department, Tamilnadu
/ immunization services/2020. Accessed 16th May 2020.
dated 09.05.2020. https://cms.tn.gov.in/sites/default/files/
go/hfw_e_181_2020.pdf. Accessed 14th May 2020. 12. Enabling delivery of Essential Health Services during
6. Rational use of personal protective equipment for the COVID-19 outbreak, Guidance note, MOHFW,
coronavirus disease (COVID-19) and considerations 25th Mar 2020. Accessed 16 May 2020.
during severe shortages Interim guidance 13. ACVIP Guidelines on Immunizations during COVID-19
6th April 2020.WHO. https://www.who.int/publications- Pandemic. www.iapindia.org. Accessed on 19th May 2020.

CLIPPINGS

CDC guidance on antibody testing.

• Do not use antibody tests to determine a person’s immune status until evidence confirms that antibodies provide
protection, how much antibody is protective and how long protection lasts.
• Antibody testing can help establish a clinical picture when patients have late complications of COVID-19 illness,
such as multisystem inflammatory syndrome in children.
• Antibody test results should not be used to diagnose someone with an active infection with symptoms.
• Antibody tests can support the clinical assessment of COVID-19 illness for people who are being tested
9 to 14 days after illness onset, in addition to recommended virus detection methods such as PCR. This will
maximize sensitivity, as the sensitivity of nucleic acid detection is decreasing and serologic testing is increasing
during this time period.
• People who receive positive results on an antibody test but don’t have symptoms of COVID-19 or have not been
around someone who may have COVID-19 are not likely to have a current infection. They can continue with
normal activities, including work, but still take steps to protect themselves and others.
• People who receive positive results on an antibody test and who are currently or recently sick or have been around
someone with COVID-19 should consult health authorities and get advice as its significance is not clear.
Content source: www.cdc.gov.National Center for Immunization and Respiratory Diseases (NCIRD), Division
of Viral Diseases Page last reviewed: May 28, 2020. Accessed on 10th June 2020.

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Indian Journal of Practical Pediatrics 2020;22(2) : 195

COVID - 19

USE OF PERSONAL PROTECTIVE large droplets. Face shields provide a barrier for suddenly
EQUIPMENTS DURING COVID-19 expelled aerosol of body fluids and are commonly used as
PANDEMIC IN RESOURCE LIMITED an alternative to goggles. Isolation gowns may be adequate
SETTINGS - THE BAREST MINIMUM for medium risk while coveralls provide full protection.
It is important to know and appropriately choose the gowns
NEEDED
based on the fabric and reliability of manufacturer.
*Dhiren Gupta All health care workers need to be taught the correct
**Simalti AK sequence of donning and doffing-PPE in order to avoid
***Arun Bansal contamination. Though not ideal, the most effective
****Neeraj Gupta methods of sterilizing and reusing N95 masks during
#
Vinayak Patki scarcity may have to be adopted.
##
Ashwani Kumar Sood
Essential protective measures depend heavily on the
###
Anil Sachdev
location of patient contact, the role of the particular health
$
Bakul Jayant Parekh
care facility and the hazard vulnerability analysis.
Abstract: Personal Protective Equipment are protective Hazards for the health care worker can be through air,
gear designed to safeguard the health care workers by surface, equipment and body secretions.
minimizing exposure to a biological agent. Personal Protective Equipment reduces the risk of
Personal protective equipment includes mask, gloves, face acquiring infection through any of these routes. This article
and eye protection (face shield, goggles), gowns and full deals with the selection of appropriate personal protective
body suits. Different types of masks are available for equipment for the health care workers managing suspected
specific purposes. Masks are intended for protecting others or proven COVID-19 infected persons.
from respiratory emissions of the wearer while respirator
Keywords: Personal protective equipments, N 95, Masks.
protects wearer from small particles like aerosols besides
Personal protective equipments PPE is important not
* Co-Director,
PICU, Sir Ganga Ram Hospital, New Delhi. only to protect Health Care Worker (HCW) but also prevent
patient to patient transmission of infection. Examples of
** Pediatric Intensivist,
Army Hospital (Research & Referral), New Delhi.
PPE include items such as mask, gloves, face and eye
protection (faceshield, goggles), gowns, shoe covers and
*** Professor,
full body suits. Picture of a heath care worker wearing full
Pediatric Critical Care,
PGIMER, Chandigarh. PPE is shown in (Fig.1).1
**** Consultant, Need for Personal Protective Equipment (PPE)
Pediatric Intensivist and Allergy Specialist, considering transmission in hospital setting
Sir Ganga Ram Hospital, New Delhi.
# Head of Department, In hospitals especially in areas where aerosols are
Pediatric Intensive Care Unit, generated, like intensive care units where droplet nuclei
Wanless Hospital, Miraj. spread quite far.2 Therefore wherever intubation and
## Professor & Head, procedures like manual ventilation, suctioning,
Deparment of Pediatric Medicine, nebulization, cardiopulmonary resuscitation,
Chief Co-ordinator MEU, IG Medical College, Shimla. bronchoscopy, throat examination, endoscopy and autopsy
### Director, PICU, are done, special precautions meant for airborne spread
Sir Ganga Ram Hospital, New Delhi. are required. 3 A very important fact or that prevents
$ National President, IAP 2020 extensive dissemination in hospitals is the presence of an
email: dhireengupta@gmail.com adequate air exchange. Ideally a negative pressure room
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Indian Journal of Practical Pediatrics 2020;22(2) : 196

Fig.2. Dust mask

virus transmission. It is used commonly in the food

Fig.1. A health care worker in full PPE and processing industry. It should not be reused as it is a
coverall single use item and cannot be washed.
with at least six air changes per hour (minimum air changes c) Cloth mask seems a practical option for usage by
recommended by WHO is 12 per hour) or natural general public.7 Cotton masks are available in the
ventilation (with airflow of at least 160 L/second is market and can even be made at home. A manual for
recommended as ideal air exchange). Another important making home made cloth masks has been released by
variable to consider is the exhaled air dispersion distance Government of India recently.8 This manual advises
during oxygen administration and ventilator support. using 100% cotton like old T shirt, cotton vest, etc.
Two to three layers of cloth is optimal as increasing
Masks layers can improve efficacy but makes breathing
Various types of masks difficult.
Masks used in the health care settings
Wearing a mask helps in preventing the aerosol spread
of COVID-19. Droplet transmission begins two and half a) Three layered surgical mask
days before patients show any symptoms in COVID
infection. Asymptomatic individuals were responsible for Surgical mask is the one which is most commonly
66% of transmission.4 In one interesting case report, an worn in healthcare settings. It consists of three layers
asymptomatic individual infected 5 out of 39 individuals (Fig.3). The inner layer has absorbent property to absorb
when he was not wearing a mask but did not infect anyone moisture from exhaled air. The middle layer acts as a filter
when he wore a mask under the same circumstances.5 and is made up of nonwoven mat of thin fiber or melt blown
Importance of wearing a mask by everyone in prevention (The melt blown process is a nonwoven manufacturing
of transmission was seen during the influenza epidemic.6 system) material. The outer most layer repels liquid.
Wearing a mask helps in preventing the aerosol spread of These masks have pleats to increase the surface area in
COVID-19. Health workers should not share the same room order to cover the chin and nose. These masks are
such as during meal time when masks cannot be worn. disposable and they do not fit tightly around face and nose.
Surgical mask prevents the release of respiratory emissions
Common (nonmedical) masks available to general from the user into their immediate environment.9 The main
population purpose of wearing these masks is to protect patients or
people nearby from the person wearing it and not the other
a) Dust mask is a disposable, molded face mask made
way around. Although not protective to wearer against
of paper pad. It does not offer any protection against
airborne infection because of their loose fit, they do protect
airborne pathogen such as corona virus. It is worn for
the wearer from direct spray or splashes of infectious body
protection against non-toxic dust (Fig.2).
fluids or blood.10 Surgical masks do not have safety rating
b) Single layer face mask which consists of a single layer but USFDA requires them to conform to certain quality
of wood pulp tissue paper or non-woven fabric. It is standards. They should have bacterial filtration efficiency
also not recommended for protection against corona more than 98%.11
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Working of respirators: Filters used in both surgical masks

as well as respirators are fibrous in consistency.
These filters are made from flat and nonwoven mats of
thin fibers made of material like wool felt, fiberglass paper
or polypropylene. Most importnat layer is melt blown layer
for filtration. This layer is 100-1000 microns in thickness
and composed of polypropylene mycrofiber with diamater
in the range of 1-10 micron, the quality of mask depends
on the quality of this layer and electro static charge over
heat. Efficiency of the filter depends on the diameter of
individual fibers, the ratio of open space to fibers termed
porosity and overall thickness of the filter. In all these
fibrous filters, there are four functional mechanisms which
enable them to capture aerosol particles. These are
interception, inertial impaction, diffusion and electrostatic
attraction. First two mechanisms namely inertial impaction
interception and electrostatic attraction are responsible for
Fig.3. Triple layer surgical mask obstructing and filtering larger particles.
Diffusion mechanism is responsible for collecting particles
Usefulness of surgical mask in preventing respiratory measuring 0.1 mm and smaller which have constant
infection: Surgical masks are the most commonly used brownian motion leading them to collide with the filter
protective device but there is not much evidence in fiber. Fourth one is electrostatic attraction which relies on
protective efficacy against airborne infection. attraction between the charged fibers and particles with
Previously WHO recommended face masks for people with opposite charge. This is very important for filter efficiency
respiratory symptoms or care givers of symptomatic as it improves efficiency in particle collection without
individuals12 but in the present scenario where a high level increasing resistance of breathing.17
of SARS-CoV2 shedding even in asymptomatic patients,
some type of barrier or mask is recommended for everyone Filtering efficacy of respirators: There are many types of
during interaction with people. Guidelines from China respirators available in market which differ from each other
recommend wearing of surgical masks based on the risk of in terms of their filtering capacity. Based on rating by
acquiring infection.13 different institutions such as CDC and European Committee
for Standardization, masks are labelled. The mask with
Surgical mask for personal protection: Since main purpose CDC 95 rating can collect at least 95% of the aerosol
of wearing a surgical mask is patient safety, most studies particles and doesn’t allow them to pass through. Similarly
have focused on chances of wound contamination and not CDC 99 rating means at least 99% aerosol particles get
on protection for the person wearing it. During the influenza filtered out and there are even respirators with CDC100
epidemic of 2008-9, this question was raised and at least rating which can filter almost 100% (practically up to
two studies have documented that surgical masks were as 99.7%) of aerosol particles. Oil can impact the efficacy of
effective as respirators for prevention of influenza among the filter used in these masks as electrostatic charges in
nurses providing care.14-16 the filter media can change on contact with oil. Thus in
b) Respirator mask industries where exposure to oil is common, respirators
need to be made resistant to oil too. This gives rise to
Respirators differ from surgical masks in their fit. another rating based on permeability of oil. These are ‘N ‘
Unlike loosely fitting surgical masks these are tight fitting. meaning not resistant, ‘R’ meaning resistant but not
Respirators are designed to create a facial seal in order to absolute while ‘P’ meaning oil proof or strongly resistant.
protect the wearer from airborne particles. They provide With these two properties-level of resistance to oil and
two way protection by filtering both outflow as well as percentage of particles filtered, these respirators can be
inflow of air. They are available as disposable device and divided into 9 categories in CDC standard. These CDC
also as full face or half face respirator device. categories are N-95, N-99, N-100, R-95, R-99, R-100,
These respirators are given ratings based on percentage of P-95, P-99, and P-100. CDC has advised that N95 respirator
aerosol they can prevent from going through. Table I should be considered as standard part of the PPE against
compares the surgical mask and respirator mask. Covid-19. European Committee for Standardization (CEN)
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Table I. Comparison between respirator and mask

Surgical mask Respirator
Testing and approval Cleared by the U.S. Food and Evaluated, tested and approved by National
Drug Administration (FDA) Institute of Occupational Safety and Health
(NIOSH)
Intended use and purpose Fluid resistant. Protects wearer from small particles like aerosols
besides large droplets
Protects the wearer against splashes, Not resistant to oil (considered in industrial use)
large droplets or sprays of hazardous
fluids. Protects others from respiratory
emissions of the wearer
Face seal fit Loose-fit Tight-fit
Air enters around the edge of mask Minimal leakage around edges when fitted
with inspiration properly
User seal check No Yes
requirement Every time it is donned
Fit testing requirement No Yes
Filtration Does NOT protect the wearer from Provides respiratory protection by filtering out at
inhaling smaller airborne particles least 95% of large as well as small airborne
particles
When to discard Disposable Ideally should be discarded after each patient
encounter
Ideally should be discarded after each Even during shortage should be discarded if: after
patient encounter. aerosol-generating procedures/becomes damaged
or deformed/Ineffective seal around the face/gets
wet or soiled/if breathing through respirator
becomes difficult.
National Institute of Occupational Safety and Health - the United States federal agency responsible for conducting
research and making recommendations for the prevention of work-related injury and illness.
uses another system namely filtering face piece (FFP), with
ratings of P1, P2 and P3 which depend on filtering capacity
of 80%, 94% and 99.95% particles respectively. So the
standard N95 of US FDA is equivalent to FFP2 of CEN.18
Fig.4 shows some of the USFDA and CEN certified
respirator masks.
c) Respirators with expiratory valve
There are many modifications done in the respirator
to increase comfort. As the filtering capacity increases,
passage of air through filter also becomes difficult.
This makes it uncomfortable for the wearer to breathe
through these respirators especially with N100 or FFP3
masks. In order to make them convenient to use, some
respirators have expiratory valve included (Fig.5).
This makes it easier to exhale and also less moisture build Fig.4. Comparison of N95, N99, and N100
up inside the mask which can be very uncomfortable to with FFP2 and FFP3 respirator masks
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offer adequate protection.22 More than 12,000 fake N95

respirator masks were seized in Bengaluru recently.23
To avoid this, dissect up one mask (cut open). One should
be able to view three layers as mentioned above. Sometimes
these similar looking masks contain only single ply or two
ply instead of three ply which is recommended.
Identification of NIOSH certified respirator

National Institute for Occupational Safety and Health

(NIOSH) approves all respirators used in healthcare settings
Fig.5. Valved vs non valved respirator to ensure standards of quality and performance.
Only NIOSH authorized manufacturer can use the NIOSH
wearer after long duration.19 However, as the exhaled air logo or NIOSH name in block letters or on respirator.
is not passing through the filter but getting out through the An established quality program to ensure respirator meeting
valve, it doesn’t protect the environment if the person the NIOSH requirements is expected from manufacturer.
wearing this mask is already infected by a respiratory Markings of NIOSH logo or name may be on the front or
pathogen. When used, wearer should be instructed to wear on the straps. Counterfeit respirators with NIOSH name or
surgical mask over respirator with expiratory valve.19 logo are often sold in market and they may be available at
d) Powered air-purifying respirator (PAPR) is supposed lower prices. NIOSH website has a list of approved
to be more comfortable for the person wearing it as it respirators and if NIOSH level is on the respirator but the
reduces heat related stress.20 A battery-powered fan is used name of manufacturer is not on the list, it may be a
in these respirators to make air flow through a filter and counterfeit product. There is also a TC number given by
facilitate easier breathing. These respirators appear to be NIOSH and with the help of TC number, buyer can verify
more protective than disposable N95 respirators but there this at the website: - http://www.cdc.gov/niosh/npptl/topics/
is no clear evidence for this.21 PAPRs are expensive, thus respirators/disp. TC number should be clearly marked on
may not be an option in the current pandemic. the packaging, on the respirator and also on the user
Other limitations are difficulty in communication because instructions. Fig.7 shows markings on a N95 respirator.24
of noise of the fan and risk of contamination during doffing. If there is no TC number on any of these items, the
It is recommended that an expert staff should assist HCWs respirator is not NIOSH-approved. NIOSH advises that
in the doffing process (Fig.6).21 even when the appropriate markings are present, any
modification like how a strap is attached to main body,
Ensuring the safety of surgical masks and can compromise safety and should not be considered as
respirators available in the market NIOSH approved.25 Before purchasing, mask should be
verified physically.
Surgical mask is expected to meet certain standards
before it can be used. Because of sudden surge in demand, Seal check of the respirator mask by wearer
many fake surgical masks have come to the market all over
the world. These counterfeit devices look like the real The user must perform a seal check after wearing the
product and even use emblems, logos, and registration respirator. This test can either be a positive or negative
numbers of the real product. Unfortunately they do not pressure check. To perform positive pressure seal check,
person exhales gently after wearing the respirator and the
face piece should become prominent and tense before
elevated pressure causes leakage of the exhaled air.
Similarly for a negative pressure check, face piece should
collapse slightly when person inhales sharply.
This procedure is called seal check and is different from a
fit test. Fit test is performed by manufacturer before
releasing respirator in market while seal check is performed
by the user. Most of the wearers have a tendency to pull
the respirator down to the chin intermittently especially
Fig.6. Example of a powered air purifying during meal time. Every time the respirator is pulled down
respirator (PAPR) it is an episode of doffing. More than 5 doffings can lead
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Example of exterior markings -

Approval holder business
name, a registered trademark
or an easily understood
abbreviation
Model # XXXX - Model
number of part number

NIOSH - NIOSH name in block Lot # XXXX - Lot number

letters or NIOSH logo and date of manufacture
(recommended, but not
required)
Exterior View

TC-Approval Number Filter Designation - NIOSH filter series,

(TC-84A-XXXX) - For products Alpha-numerical rating followed by the
manufactured after September 2008, filter efficiency level (for example, N95,
the TC-approval number is required N99, N100, R95, P99, P100)
to appear on the product

Fig.7. Example of exterior markings on NIOSH approved respirator

For more information about NIOSH-Approved respirators, to to: http://knowits.NIOSH.gov

to poor seal. If user ensures proper seal then respirator can e) Elastomeric respirators are half-facepiece, tight- fitting
be used till it is hard to breathe. After touching front of the respirators that are made of synthetic or rubber material
respirator, hand hygiene should be performed. permitting them to be repeatedly disinfected, cleaned, and
reused. They are equipped with replace able filter
Facial hair interfering with respirator seal
cartridges. Similar to N95 respirators, elastomeric
Ensuring proper seal is a vital part of effective respirators require annual fit testing. Elastomeric
respiratory protection. Facial hair such as sideburns, respirators should not be used without surgical mask over
mustaches and beards, can interfere with the sealing area it due to concerns that air coming out of the exhalation
of a respirator. This may lead to failure of creating a tight valve may contaminate surrounding area.
seal to achieve maximum protection. Small particles in the
air take the path of least resistance and through facial hair Face Shield and goggles
can bypass the filter of respirator. Hair is much larger in Role of face shield as part of PPE
size and not dense enough to act as an effective filter.26
Facial hair under the sealing area causes significant leakage A face shield provides barrier protection to the
when compared to a clean-shaven person. Even 2 days facial area and the related mucous membranes (eyes, nose
stubble can reduce protection. Generally, as per CDC, hair and lips). It provides a barrier to a bout of suddenly-
should not cross under the respirator sealing surface. expelled aerosol of body fluids and are commonly used as
Alternatives to N95 NIOSH approved / FFP2 / an alternative to goggles as they confer protection to a larger
FFP3 masks area of the face.27 Combination of this face shield and an
N95 filtering facepiece respirator (N95 FFR), protects the
These include other classes of filtering face piece eyes, nares and mouth from contamination better than N95
respirators, elastomeric half-mask and full face piece air combined with goggles.
purifying respirators, powered air purifying respirators
(PAPRs). All these alternatives will provide equivalent or Effectiveness of face shield for protection against droplets:
higher protection than N95 respirators when properly worn. For droplet size more than 5 micron, the efficacy is 96%
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(for aerosol spread from distance of 45 cm). If the droplet

size is reduced to less than 3.4 μm, the efficacy goes down
to 23% upto 30 min following cough (during which time
the larger aerosol particles settle out, droplet nuclei form
and remain airborne so that flow occurs more easily around
the edges of the face shield).28
Situations to wear face shield: Face shield should be worn
during patient care activities where splashes and sprays
are anticipated, typically aerosol generating procedures and Fig.8. Face shield with visor, frame and
during activities where prolonged face-to-face or close suspension system
contact with a potentially infectious patient is unavoidable. completely. Visors manufactured from acetate, propionate,
Face shields should not be used while intubating because and polycarbonate offer improved visual clarity and optical
aerosols can flow behind the visor hence goggles should quality with the potential for less eye strain. Brow caps or
be worn. Face shield and goggles should not be used forehead cushions should be of sufficient dimensions to
together as it does not offer additional protection and ensure that there is adequate space between the wearer’s
causes more discomfort and fogging affecting vision.27 face and the inner surface of the visor to allow for the use
Precautions while using face shield: Health care worker of ancillary equipment (medical/surgical mask, respirator,
should take care not to touch their face shield. If they touch eyewear, etc.). There is currently no universal standards
or adjust their face shield, they must immediately perform for face/eye protection from biological hazards.
hand hygiene. If they need to remove their eye protection, Face shields are marketed as class 1 medical devices
they should leave patient care area. Face shield should be exempt from FDA pre market notification.27
taken off as late as possible, preferably at the end of the Selection of appropriate goggles: Goggles should have a
procedure to prevent inadvertent exposure of the mucous good seal with the skin of the face. Frame should be flexible
membranes when other potentially contaminated PPE to easily fit all face contours without much pressure on the
components are being removed.27 Face shields with single skin. It should cover the eyes and the surrounding areas
Velcro or elastic straps tend to be easiest to don and doff. (through the silicon rim) and accommodate the prescription
Doffing can be accomplished with a single hand. glasses underneath. It should have a fog and scratch-
It should be discarded if damaged. resistant adjustable band that can be firmly secured and
Components of a face shield: The major structural does not become loose during clinical activity.
components of a face shield include a visor which is the Goggles should have an indirect venting mechanism to
transparent part of face shield. Ideally width should be reduce fogging. Goggles can be reusable (provided
sufficient to reach at least the point of the ear on both sides appropriate arrangements for decontamination are in place)
(Fig.8). The purpose is to lessen the chances of the splash or disposable.
reaching the eyes and oral cavity. In addition, visors should Reuse of face shields and goggles: Face shields should be
have crown and chin protection for improved infection reused only if they are made of robust material like
control purposes. It is made of either polycarbonate polycarbonate propionate or acetate. Though propionate
propionate, acetate, polyvinyl chloride, and polyethylene has the best clarity acetate is most commonly used. Face
terephthalate glycol. Visor is available in disposable, shield should be dedicated to one HCP only.
reusable, and replaceable models. Visors can be treated WHO recommends cleaning with soap/ detergent and water
with advanced coatings to impart anti-glare, and disinfection with 70% alcohol or sodium hypochlorite
anti-static, and anti-fogging properties, ultraviolet light 0.1%; finally rinsing with clean water. Isopropanol (IPA)
(UV) protection, and scratch resistance features to extend 75%, 95% or 99% for 5 mins, ethanol 70% for 5 mins,
the life. sodium hypochlorite 1% for > 5mins or UV-C for 15 mins
Choice and regulatory standards for face shields: are the methods recommended for sterilising face shields
Face shield should be made of clear plastic and it should and goggles. Autoclave, steam or ethanol > 80% are not
provide good visibility to both the wearer and the patient. recommended.
There should be an adjustable band to allow good fit around Medical gowns
the head and snug fit against the forehead also to prevent
slippage of the device. Visor should ideally be fog-resistant Types of gowns
and should cover the sides and length of the face Several types of protective gowns are available as part
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of PPE. These include a) aprons b) surgical gowns Clothing material for gowns: Isolation gowns are made
c) isolation gowns d) coveralls. Aprons cover only torso either of cotton or a spun synthetic material that decide
and they are used occasionally where limited contamination whether they can be laundered and reused or must be
is anticipated. A surgical gown protects both the patient disposed off. The clothing material should be impermeable
and health care worker from contamination. Front of the to blood, body fluid and to COVID virus sized 0.11microns.
body from top of shoulder to knees and the arms from above Reusable gowns made of cotton are not impermeable to
elbow to the wrist cuff are the critical zones most prone blood or fluid so they do not provide protection against
for receiving splashes during procedures. These parts of transmission of pathogen.29 Recently gowns made up of
surgical gown are provided with extra protection while microfibers have been introduced in medical field as
other area is made of normal material. Isolation gown replacement for cotton gowns since they can be reused.
differs in that all areas of the gown except bindings, cuffs,
Of the materials used for making gowns, non woven
and hems are considered critical zones and must meet the
fabric is criss cross and functions as filter against fluid,
highest liquid barrier protection level. All seams must have
blood, bacteria and viruses and also impermiable. The three
the same liquid barrier protection as the rest of the gown
most commonly used non woven fabrics for surgical gowns
(Fig.9). Isolation gowns are used when there is a medium
and drapes are - i) Spunlace, ii) Spunbond-meltblown-
to high risk of contamination. These gowns do not provide
spunbond (SMS) and iii) Wet-laid
extended whole-body protection due to possible openings
in the back or neck and coverage upto the mid- calf only as Most popular amongst these is spunbond meltblown
compared to cover all suits or Hazmat suits which provide spunbond, known as SMS.
360 degree protection (Fig.2). Coveralls and gowns are Recommendations on gowns
deemed equally acceptable.
Government of India requires that all gowns should
Quality check when ordering gown or coverall for PPE: have following information printed by manufacturer.30
Gowns should be made of light weight fabric and it should
fully cover the torso, It should comfortably cover the body • Name of manufacturer
and should have long sleeves that fit snugly at the wrist. • South India Textile Research Association (SITRA)/
It is important to have sufficient overlap of the fabric so Defence Research and Development Establishment
that it wraps around the body to cover the back ensuring (DRDE) /Institute of Nuclear Medicine and Allied
that if the wearer squats or sits down, the gown still protects Sciences. (INMAS) Unique Certification Code (UCC)
the back area of the body. Light colours are preferable over • Test standard
dark ones to better detect possible contamination. • Date of manufacturing / batch number
Coverall should be designed to have universal fit. It should
have inbuilt hood cap. Zipper of the coverall should be The same UCC seal should be found on each gown.
covered with a flap to avoid accumulation of microbes. Manufacturer can be verified on sitra.org.in or DRDE
It should be ensured that the gown or coverall being website ISO/FDIS 16603 class 3 is the minimum
procured meets or exceeds ISO 16603 class 3 exposure requirement for COVID 19 isolation ward.
pressure.
Another very important factor is the breathability
which should be checked. This is very important for
comfort of wearer. The breathability is tested by air
permeability (AP) and water/moisture vapor transmission
rate (WVTR/MVTR) of fabric. These tests should be done
as per ambient temperature where the PPE will be used.
Gown fabric must have the following range of AP and
WVTR/MVTR:
a. Air permeability (L/M2/minute):100-150

Fig.9. Surgical gown (left) gives extra b. Water/moisture vapor transmissionrate-WVTR/

protection to front and sleeves only whereas MVTR (g/M2 /day): 400–500
isolation gown (right) gives 100 percent Shortage of gowns during the pandemic: Extended use,
protection (Unprotected area C, D; protected reprocessing, or use of alternative gown can be considered
A,B,E,F) temporary and should be avoided as much as possible when
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caring for severe or critically ill COVID-19 patients. Donning and doffing PPE
These alternatives should also be avoided when performing
aerosol-generating procedures and constant contact for Employers are required to train every employee who
more than 30 minutes in same environment or close contact must use PPE about how to properly put on (Donning),
(within1meter) for more than 15 minutes.31 If someone has take off (Doffing), adjust and wear the PPE.
an old gown without UCC stamp and wants to check for Everyone working in a health care facility must be trained
permeability, there is a crude method (not evidence based) to know about situations where PPE is necessary and also
to check gown fabric and seam. Pour 2 glasses of water what kind of PPE to choose, its limitations and proper
over gown including seam. If no leak is found after disposal after use.
2 minutes especially over the seam, then it can be used for Individuals are instructed first to perform hand
desired purpose. Same test can be used to assess the gowns hygiene and then the sequence of first gown followed by
which do not have this certificate (pushed in market as surgical mask, eye protection and gloves in the end.
laminated products and are cheap). Clinician should always The order of doffing is gloves first followed by gown, eye
remember that these low cost, unapproved gowns may be protection and surgical mask in the end (Table.II).
used for low risk areas like outdoor patient services but
should be avoided in isolation areas especially ICU or any N95 is a tight-fitting respirator, it is not effective when
aerosol generating areas. Many of these products are it is not properly fitted, It needs to create a tight seal.
uncomfortable to wear as they are either too heavy Seal test is performed by inhaling after respirator is worn.34
(laminated cotton based) or non-breathable. Therefore If seal is good it should get puckered in slightly. It should
before purchasing in bulk, user should try and test PPE for be done every time a respirator is worn.35 Practical tips to
at least 3 hours in actual condition or run on treadmill for remember while donning and doffing PPE are shown in
15 minutes (2.5 miles/ hour). Look for the comfort, sweat Table III.
and heat generated beneath fabric. Another weak point is
Tips to remember when donning a mask or respirator ties
the cuff. Ideally Gloves should overlap the cuff of gown
of mask/respirator should be tiedup at middle of head and
so that no portion should be left exposed.
neck
Precautions while wearing gowns for extended duration:
Extended use means using the same gown, when providing Tackling the scarcity of PPE
care to a cohort of patients with COVID-19. This may
Reuse of PPE
increase risk of contamination with COVID-19 virus and
may increase the risk of transmission of other pathogens Conventionally disposable items are one time use only
between patients. Gown should be removed whenever it after which they need to be disposed. Reuse should be done
becomes wet, soiled, or damaged or exposed to splash of by single person only and should never be shared between
chemicals, infectious substances, or bodyfluids.32 different persons. Recommendations have been issued for
Cotton re usable gowns for PPE: Cotton reusable gown is limited reuse or extended use of disposable respirators
not impermeable to fluid hence, does not provide adequate and masks. Reuse is not recommended if used for any
protection. If due to circumstances cotton reusable gown procedure which may result in aerosol generation like
is used, it should be combined with barrier polyester suction, intubation, bronchoscopy etc.36 Respirators should
sheeting which is worn above gown, with a property of be discarded if seal is not adequate around mouth and nose
water-repellent chemical finish. Main problems are thermal or become moist from exhaled air or sweat or soiled or
discomfort as these are nonbreathable and lack of protection damaged (Table I).37
of arms and the back of the torso, which can be exposed to Practical methods of sterilizing and reusing
splashes.33 N95 masks
Washing and disinfection of cotton gowns: Washing by
Air drying: Drying for at least 72 hours kills the
machine with warm water (60-90°C) and laundry detergent
coronavirus. Drying the used respirator in a clean, dry place
is recommended for reprocessing of the gown. If machine
for 3 days is one practical way for reusing the mask.
washing is not possible, linen can be soaked in hot water
and soap in a large drum, using a stick to stir, avoiding AIIMS, Delhi protocol: Health care workers are issued
splashing. It is then soaked in 0.05% chlorine (hypochlorite 5 masks and 5 marked paper bags. They are supposed to
solution) for approximately 30 minutes. Finally, it is rinsed use one mask a day and then keep it in the paper bag and
with clean water and sundried. use next mask for day 2 and so on for next 4 days till by
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Correct sequence of wearing PPE (Fig.10)

Fig.10. Sequence for putting on and safely removing PPE Source: CDC
All health care workers need to be taught the correct sequence of wearing (Donning) and taking off (Doffing) the PPE in
order to avoid contamination.

rotation first worn respirator comes again. Table II. Suggested sequence of donning and
Maximum reuse of N 95 mask by a single user is 5 times.38 Doffing PPE
Paper bag should be kept away from direct sunlight and
ultraviolet rays. If the respirator becomes damaged, soiled Donning sequence Doffing sequence
or breathing becomes difficult, it is no longer fit to be used. Hand hygiene Outer gloves
Person wearing it should be familiar with method of
removing and wearing it properly. Cap Gown/ cover all
Heat in an oven Shoe cover Shoe cover
i) Heat the respirator at 70 OC for 30minutes after Hand hygiene Goggles / face shield
confirming that it is not inflammable and does not have
a metal clip. Respirator can be hung in the oven using Inner glove Mask
a wooden clip.39
Gown/ cover all Cap
ii) Microwave (one minute each side) can also be used.
Mask (Surgical mask or Inner glove
Chemical sterilization N95 Respirator)
Vapor of hydrogen peroxide is used for sterilising used
Goggles / face shield Hand hygiene
respirators.40,41 During 2009 influenza epidemic, NIOSH
had compared 5 methods of disinfection namely microwave Outer gloves

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Table III. Practical tips to remember when scraps of paper-if the paper sticks, the electrostatic charge
donning and doffing off mask, respirator and has been restored.
face shields
Storing the respirator or face mask during
Tips to remember when donning a mask or reuse
respirator
All respirators or facemask should be stored in a
Ties of mask/respirator should be tied up at middle of container made of material that allows breathing like paper
head and neck bag. Name of user should be placed on the respirator or
face mask as well as storing container in order to prevent
Flexible band should be at the nose bridge.
reuse by another person. Name on mask can be written on
It should fit snugly to face and below chin the straps of respirators. Date and time should be writtenon
Respirator should be tested every time it is worn by the container bag to track duration of use.43
inhaling deeply after wearing and it should pucker in Choice of mask to be worn
slightly.
With the ongoing pandemic it is now clear that if
Tips to remember when doffing a mask or respirator everyone wears a mask, chances of virus transmission
Front of mask/respirator is contaminated and it should significantly goes down.Triple layer surgical mask seems
never be touched an ideal choice but it has to be disposed after getting soiled
and may need frequent replacement even within a day.
If hands get contaminated during removal of mask/ A washable three layered cotton cloth mask can be a more
respirator, immediate hand hygiene should be performed. practical option for the general public. Irrespective of
Mask should be removed by grasping bottom ties or the type of mask worn, the person wearing it needs to know
elastics and then the ones at the top. the proper way of wearing it and general precautions - hand
hygiene before wearing and after removing, not to touch
Mask/ respirator should be removed without touching
the mask while it is on the face of the user. Dust mask and
the front
single layer mask should not be used and surgical mask
Disposable item should be discarded in a designated should not be washed or reused. The N95 respirator mask
container should not be used in the community as it is a precious
commodity. Mask should be worn even inside the house if
Tips to remember when doffing a face shield some one is having a respiratory infection. During this
Outside of face shield is contaminated and it should pandemic all HCWs should wear a respirator when sitting
never be touched. in the outpatient department (OPD), irrespective of nature
of OPD. All patients and accompanying attendants must
If hands get contaminated during removal of face shield,
be made to wear a mask before entering OPD.
immediate hand hygiene should beperformed.
During aerosol generating procedure N95 mask is
Face shield should be removed by lifting ear pieces or mandatory. Doctors and nurses are at maximum risk of
head band from the back. acquiring infection hence no compromise should be made
Disposable face shields should be discarded in a with respect to wearing adequate PPE.44
designated receptacle Issues faced by HCW while using PPE
If reusable, face shield should be placed in designated Danger of hypoxia and carbondioxide retention after
container. extended use of respirator
oven irradiation, bleach decontamination, ultraviolet Many clinicians feel claustrophobic after wearing
germicidal irradiation (UVGI), ethylene oxide (EtO) and tight fitting respirators, but significant hypoxemia or carbon
vaporized hydrogen peroxide (VHP). Out of these UVGI, dioxide retention of clinical significance has not been
EtO and VHP methods were found to be promising proven.
decontamination methods.40,42 Cleaning the mask with soap,
Common injuries on wearing respirators
alcohol, bleach or isopropranolol have not been successful
as they caused damage to the electrostatic charge thus Long hours of wearing the N-95 respirators or surgical
significantly reducing the filtration capacity.42 Successful masks and goggles can compress nose-bridge and cheeks,
regeneration is confirmed by sprinkling the mask with small the mask strap can compress the ears, and face shield and
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Table IV. Summary of quality standard for various components of PPE.

No Equipment Specifications Quality Standard
1 Coverall suit / S-spunbound, M-meltdown 1. Meets or exceeds ISO 16603 class 3
Surgical gowns • SMS (GSM >70) exposure pressure
• SMMS (GSM >70) 2. UCC stamp from SITRA or DRDO
• SMMMS (GSM >70)
• Single use only
• Light colors
GSM alone should not be the criterion to
select cloth but all these fabrics and seams
should be approved by SITRA or DRDO /
INMAS. Each and every gown should have
stamp on individual product.
2 Gloves • Nitrile 1. EU standard directive 93/42/EEC Class I,
• Non-sterile EN455
• Powder free 2. EU standard directive 89/686/EEC
Category Ill, EN 374
3. ANSI/SEA 105-2011
4. ASTM D6319-10
3 Goggles • Accommodates prescription glasses 1. EU standard directive 86/686/EEC
• Adjustable band 2. EN 166/2002
• Indirect venting to reduce fogging 3. ANSI/SEA Z87.1-2010
• Disposable
4 Shoe cover Made up of the same fabric as of
coverall/gown
5 N-95 Masks 1. NIOSH - approved N95 or Made in India masks either should be
2. EN 149 & FFP2 or FFP3 certified by NIOSH (CDC web site) or
3. Fluid Resistance - ASTM F1862, approved by SIRA or DRDO
ISO22609, or equivalent”
6 Face Shield • Made of clearplastic 1. EU standard directive 86/686/EEC, EN
• Adjustable band 166/2002
• Fog resistant (preferable) 2. ANSI/SEA Z87.1-2010
• Disposable

surgical cap can compress the forehead, which might be without intervention; for blisters with a large area or
the main cause of pressure injuries on multiple parts of high tension, a sterile syringe is used to suction out
the head and face. Following are the strategies to prevent the fluid from the bottom of the blister, topical
and treat them. antibiotic ointment is applied and epidermal loss
1. Apply hydrogel and hydrocolloid dressings beneath should be avoided.
N95 mask as a preventive measure Precautions during aerosol-generating
2. Adequate cleansing and applying moisturizers procedures
(coconut oil, over the counter moisturizers like Aerosol-generating procedures are nebulization,
Vaseline lotion or moisturizing cream) over pressure HFNC, endotracheal intubation, airway suction,
areas frequently will help. tracheostomy procedures and UGI endoscopy,
3. If injury has occurred - for small sterile blisters, where tracheostomy, bronchoscopy and cardiopulmonary
the epidermis is intact, the blister fluid will be absorbed resuscitation. Non invasive ventilation is also an aerosol
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Table V. Strategies to optimize PPE and Equipment during pandemic

N95 Respirators Facemasks Eye Protection
Conventional Recommended only for use by Use based on local guidelines Based on local guidelines
Capacity HCW for protection from airborne
as well as fluid hazards.
Contingency Use beyond the manufacturer- Restriction on use of facemasks goggles and reusable face
Capacity designated shelf life for training only by HCP. Do not keep shields to be preferred over
and fit testing. Extended use and facemasks in public areas for disposable onesImplement
Limited re-use for tuberculosis visitors extended use. extended
and non Covid cases
Crisis Capacity Use beyond the manufacturer - Use beyond the manufacturer- Use beyond the
designated shelf life also for health designated shelf life limited manufacturer - designated
care limited re-use COVID-19 re-use. shelf life limited re-use
patients. Prioritize the use of Prioritization for selected Prioritization for selected
respirators based on type activity. activities. activities.
Use of respirators other than
standard N95 (should be considered
equivalent in standards prevalent in
other countries)
No PPE available Non-NIOSH approved masks or A face shield that covers the
even home made masks. entire face extending to the
chin or below and sides of the
face with no face mask.

generating procedure.46 Ideally these procedures should be Checklist for PPE kits required for HCWs is available
done in rooms with negative pressure and atleast as guidelines issued by MOHFW, GOI and WHO
12 air changes per hour or room with natural ventilation (Table V).
with airflow 160 L per second per patient.47 PPE for HCW
performing any of the procedures discussed above should In view of constantly changing epidemiology
include double gloves, impervious gown with long-sleeves, (especially increase in asymptomatic spread) guidelines
eye protection with goggles and face shield and a N95 can be modified as per resources available.
respirator mask. Selection of PPE in specific situations
Behavior and compliance issues related to PPE In non COVID / suspect COVID cases (Awaiting report)
Since wearing the PPE for long time can be
In ICU / Emergency - Above full set of PPE is essential
uncomfortable with difficulty in breathing, compliance may
(preferably single use)
not be optimal. Compliance for wearing gloves is high
while compliance for wearing eye protection was lowest In ICU / Emergency (limited resources) - Above PPE
in one questionnaire based survey.48 In another survey, (Reprocessed)
availability of PPE, safety culture of unit and training of
HCWs were found to be determinants of improving Non critical areas (wards with Covid negative cases, areas
compliance among HCWs.49 Everyone working in a health without aerosol generating procedure) - head cap, reusable
care facility must be trained to know about situations and gown, face shield, goggles, gloves. Three ply surgical mask
type of PPE necessary. They should be taught about how or N95 mask.
to properly put on, take off, adjust and wear the PPE. If suspected case turns positive - Full set of PPE is
They should be aware of limitations of the PPE and about essential to the health care workers handling (Single use).
proper disposal of PPE. Quality standards acceptable for
PPE have been shown in Table IV. If resource limited reprocessed full set of PPE can be used.
95
Indian Journal of Practical Pediatrics 2020;22(2) : 208

In ICU and Emergency ward - Health care workers to be in on home made masks. 2nd Apr, 2020. https://pib.gov.in/
the full PPE with all elements (based on availability) Press Release I frame Page. aspx?PRID=1610191.
considering all cases to be as suspected COVID. Accessed on 4th Apr 2020.
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used. 10. Oberg T, Brosseau LM. Surgical mask filter and fit
performance. Am J Infect Control 2008; 36(4):276-282.
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11. Rengasamy S, Shaffer R, Williams B, Smit S.
• Health Care Workers should wear appropriate A comparison of facemask and respirator filtration test
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(in Chinese). Feb 5, 2020. http://www.gov.cn/xinwen/
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level of protection as they cover larger critical zones Kidd TJ, Johnson GR, Knibbs LD, Morawska L, Bell SC.
than traditional surgical gown. Face masks reduce the release of Pseudomonas aeruginosa
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CLIPPINGS

Contact tracing assessment of COVID-19 transmission dynamics in Taiwan and risk at different exposure
periods before and after symptom onset.
This prospective case-ascertained study in Taiwan included laboratory-confirmed cases of COVID-19 and their
contacts, from January 15 to March 18, 2020. All close contacts were quarantined at home for 14 days after their
last exposure to the index case. During the quarantine period, any relevant symptoms (fever, cough or other
respiratory symptoms) of contacts triggered a COVID-19 test. Secondary clinical attack rate (considering
symptomatic cases only) for different exposure time windows of the index cases and for different exposure
settings (such as household, family and health care) were analysed . Here 100 confirmed patients were enrolled,
with a median age of 44 years. Among their 2761 close contacts, there were 22 paired index-secondary cases.
The overall secondary clinical attack rate was 0.7% (95% CI, 0.4%-1.0%). The attack rate was higher among the
1818 contacts whose exposure to index cases started within 5 days of symptom onset [1.0% (95% CI,
0.6%-1.6%)] compared with those who were exposed later (0 cases from 852 contacts; 95% CI, 0%-0.4%).
The 299 contacts with exclusive presymptomatic exposures were also at risk (attack rate, 0.7% [95% (CI, 0.2%-
2.4%)]. The attack rate was higher among household (4.6% [95% CI, 2.3%-9.3%]) and non household
({5.3% [95% (CI, 2.1%-12.8%)}) family contacts than that in health care or other settings. The attack rates were
higher among those aged 40 to 59 years (1.1% [95% CI, 0.6%-2.1%]) and those aged 60 years and older [0.9%
(95% CI, 0.3%-2.6%)]
Conclusions: High transmissibility of COVID-19 before and immediately after symptom onset suggests that
finding and isolating symptomatic patients alone may not suffice to contain the epidemic and more generalized
measures may be required, such as social distancing.
Cheng HY, Jian WS, Liu DP, Ng TC, Lin HH. Contact tracing assessment of COVID-19 transmission
dynamics in Taiwan and risk at different exposure periods before and after symptom onset. JAMA Internal
Medicine / Original Investigation. JAMA Intern Med. doi:10.1001/jamainternmed.2020.2020. Published online
May 1, 2020.

Reactive lymphocytes in patients with COVID-19.

The peripheral blood films of 32 patients out of 96 COVID-19 cases confirmed in Singapore by RTPCR were
examined and reactive lymphocytes were found in 23 cases (72%). The most common subtype seen in this
cohort displayed a distinctive abundant pale blue cytoplasm that often abuts adjacent red blood cells. This type
of reactive lymphocytes were not seen in 185 SARS cases in Singapore during the 2003 outbreak and were seen
in only 15.2% of 138 cases in Hong Kong. Lymphoplasmacytoid lymphocytes were present in 16 out of
23 patients. These are small mature lymphocytes with condensed chromatin and an eccentric nucleus. Both
types of cells can coexist. The latter cells are also seen in dengue and B-NHL. This is an observation seen in the
peripheral smears of COVID-19 patients, significance is not known at present.
Vanessa CL Chong, Kian Guan Eric Lim, Bingwen Eugene Fan, Stephrene SW Chan, Kiat H Ong, Ponnudurai
Kuperan. Reactive lymphocytes in patients with COVID-19. British Journal of Haematology 2020;189(5)
844.
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Indian Journal of Practical Pediatrics 2020;22(2) : 211

COVID - 19

MENTAL HEALTH SUPPORT FOR • Concern over economic slowdown and fear of losing
PATIENTS AND PROFESSIONALS livelihood including losing jobs, pay cuts, lockouts,
financial stress and possible life style changes.
*Jayanthini V
**Kannan Kallapiran • Increase in domestic violence and marital discord.
• Living alone with no social support or inability to go
Abstract : Covid-19 has created an unprecedented health back to their native places/not being allowed to enter
and economic crisis worldwide. Issues compounding the their villages resulting in social stigma.
crises are - ongoing uncertainty about duration of the
pandemic, challenges for health care workers in handling • Non-availability of liquor and other addictive drugs.
patients and personal lives and the enormous economic • Extreme work pressure and burnout in the case of
and social costs for the public at large. All these have led frontline workers.
to enormous impact on the mental health of the community,
patients and health care professionals. This article aims Elderly: These people have enormous health anxiety due
to highlight the extent of the impact of COVID on mental to their chronic medical illness, fear of death or becoming
health and the support required for patients and a burden to the family, needing the help of paid caregivers
professionals. who are unavailable due to COVID and being alone with
or without the spouse as the family members live
Keywords: Covid induced stress, Mental health, elsewhere.3 They also worry about the well-being of their
Emotional, Stress, Medical resilience, COVID -19. stranded/locked out quarantined family members.
In addition, many of them develop a fear of being neglected
A survey conducted in India indicated that more than due to financial crunch or worry that their children may
80% of Indian adults surveyed online, were preoccupied not be able to come for their last rites in case of death.
with COVID-19 with higher levels of anxiety, sleep Contact with family, relevant information, phone
disturbances, paranoia about getting infected with counselling, general medical and psychological needs,
COVID-19 and distress about social media.1 Similarly in personal space and respect of dignity were important
China, over 75% were worried about family members components in enhancing mental care in elderly during
contracting COVID-19, 53.8 % had moderate to severe SARS epidemic.4
psychological impact, 28.8% and 16.5% had moderate and
severe levels of anxiety and depression respectively.2 Victims of domestic violence: A recent report from WHO
says that there is a 60% rise in domestic violence calls in
The reasons for the above mentioned psychological Europe. UN WOMEN also has reported increased violence
disturbances include against women and children including physical, emotional
• Fear of contracting the virus and being quarantined. or sexual abuse. Special helplines in India reavailable for
women in distress and they can get free counselling and
• Anxiety about the wellbeing of family members, help (Ph: 1091).WHO has released a fact sheet about
especially for the frontline workers or those living in domestic violence and what women can do protect
severely affected areas and countries. themselves.5

* Retd. Professor of Pediatric Psychiatry Home and institutionally quarantined: Those

Madras Medical College, HOD, Child Health Clinic, quarantined go through anxiety, depression, low mood, fear,
Institute of Child Health and Hospital for Children, nervousness, irritability, boredom, frustration and sleep
Chennai disturbances which can lead on to acute stress reaction or
** Consultant - Child Psychiatry, exacerbation of preexisting psychiatric conditions. 6
Gold Coast Hospital, Australia. Providing them with necessary information to allay their
email: jayanthini@yahoo.com fears, adequate supplies to meet their needs, options to
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Indian Journal of Practical Pediatrics 2020;22(2) : 212

occupy themselves and communication have been with little or no incentives, non-availability of expensive
recommended.We need to reinforce that quarantining is personal protective equipment (PPE), inability to eat/ sleep
helping their family to remain safe. They should be properly, not visit toilets for 8 hours or more, disheartening
provided a free helpline or point of contact to address their social ostracism, harassment and at times assaults.
concerns. In addition, they are unable to complain or quit as it is
politically and ethically incorrect. The workers also face
Children and adolescents: Managing children across all burn outs and are unable to visit their families. Hence their
ages within the confines of the home without access to physical, psychological wellbeing is of utmost importance
school, outdoor play, peer group and extracurricular during this time. While the COVID patients and those
activities can be very challenging. Some parents are unsure quarantined get counselling, it is important that we provide
how to discuss the COVID situation to their children in a this to the frontline professionals as well.
way they can understand. Centre for the study of traumatic
stress (CSTS) has provided a fact sheet with different Simple and practical interventional
strategies to discuss this across different age groups and strategies
can be accessed in the link provided below.7 Their energy
needs to be channelized by continuing their extracurricular The professional’s duty at this juncture is to cure
classes like dance, or music online and free remote learning sometimes, to relieve often and to comfort always to quote
of activities like using www.Pschool.in. Those who cannot the 16th Century aphorism. Hence, empathetic listening and
afford these should be told/read stories, entertained with skilled counselling are to be practiced to address the
board games or our traditional, indoor play activities. emotional, social and spiritual needs which include the
Each family needs to devise their own practical and simple teaching of practical skills to cope with the situation which
ways. NalandaWay an NGO has created ‘Art for Wellbeing differs from person to person
- A Parent’s Guide’ which has age-specific art activities 1. Accept their emotional stress non judgmentally and
for children to manage emotions during this time. It can be ensure confidentiality.
accessed via https://www.nalandaway.org/covid.php.
2. Create an environment of acceptance and taking
The plight of children who are quarantined away from positive action - encourage them to ventilate their
parents because either the parent tested positive and was feelings and ask for help as necessary.
taken away or the child is hospitalized. Those who were
3. Learn to break bad news and handle grief reaction.
separated from parents in such situations were more likely
to suffer from acute stress disorder, adjustment disorder 4. Help sort out problems by effective communication
and grief. Nearly 30% fulfilled criteria for post traumatic with significant others.
Stress disorder.8 As far as possible it is important not to 5. Give simple reliable information from neutral sources
separate children from their parents. In the unlikely such as WHO, ICMR, Indian Academy of Pediatrics
eventuality, other forms of support such as relatives, known and reputed journals.
family friends, nurses and counselling psychological
supports have been recommended. 9 6. Check for overestimating the problem and avoid
negative contagion - reduce the infodemic through
Those with developmental disorders like autism rumors and fake news - social media distancing.
spectrum disorders, cannot get accustomed to a change of
7. Maintain a routine of daily activities (adequate sleep,
routine and staying within the confinement of their homes
healthy eating, exercise, meditation, yoga, time for
for weeks together, resulting in acute behavioral changes
hobbies) and regular social contacts.
including assaultive and destructive behavior, in which case
family should contact their mental health provider. 8. Ensure adequate family time for interactions,
discussions and to prepare the children for life style
Healthcare professionals: They witness extreme changes as normalcy will be redefined.
suffering, deaths and do not have time to mourn.
Hence, they can have disturbed sleep, nightmares, 9. Never hesitate to ask them to get in touch with mental
frustration but have to maintain an outward calmness and health professionals, especially if they have suicidal
empathetic outlook, and some of them develop post- ideation, worsening of symptoms inspite of adequate
traumatic stress disorder (PTSD) later.10 Professionals and intervention and when they are aggressive, sleepless,
health care workers’ problems are further enhanced because experience severe health anxiety or indulge in self
of continuous and direct exposure, extended hours of work injurious behavior.
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Indian Journal of Practical Pediatrics 2020;22(2) : 213

10. Provide contact details for free online counselling 3. Banerjee D. The Impact of COVID-19 Pandemic on
offered by NGOs, Indian Psychiatric Society and other Elderly Mental Health. Int J Geriatr Psychiatry 2020;
helplines like Therapists Collective. doi:10.1002/gps.5320.
4. Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, et al.
Those who are interested in practical strategies to enhance The psychological impact of the SARS epidemic on
their resilience can access the 3 session video course on hospital employees in China: exposure, risk perception,
resilience training for health workers by Massachusetts and altruistic acceptance of risk. Can J Psychiatry
General Hospital by clicking on this link https:// 2009;54(5), 302-311. doi:10.1177/070674370905400504.
www.resilienceandprevention.com/healthcare-providers. 5. WHO. COVID-19 and violence against women. 2020;
Available from https://apps.who.int/iris/bitstream/handle/
Conclusion 10665/331699/WHO-SRH-20.04-eng.pdf. Last accessed
COVID-19 like other pandemics causes enormous on 5th May 2020.
strain on the mental health of people in the community, 6. Brooks SK, Webster RK, Smith LE, Woodland L,
patients and health workers. It is important to organise Wessely S, Greenberg N, et al. The psychological impact
of quarantine and how to reduce it: rapid review of the
adequate support to mitigate the severity of its impact.
evidence. Lancet 2020;395(10227), 912-920. doi:10.1016
Early identification of worsening mental health and prompt /S0140-6736(20)30460-8.
response to address the same can prevent things from
7. CSTS. Discussing Coronavirus with your children. 2020 ;
worsening. Let’s remember not to be consumed by negative
Available from https://www.cstsonline.org/assets/media/
contagion, provide accurate information where required documents/CSTS_FS_Discussing_ Coronavirus_w_
and maintain focus on what is within our influence. Your_Children.pdf. Last accessed on 5th May 2020.
References 8. Sprang G, Silman M. Posttraumatic stress disorder in
parents and youth after health-related disasters. Disaster
1. Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Med Public Health Prep, 2013 ; 7(1), 105-110. doi:10.1017
Kaushal V. Study of knowledge, attitude, anxiety & /dmp.2013.22.
perceived mental healthcare need in Indian population 9. Liu JJ, Bao Y, Huang X, Shi J, Lu L. Mental health
during COVID-19 pandemic. Asian J Psychiatr, 2020;51, considerations for children quarantined because of
102083. doi:10.1016/j.ajp.2020.102083. COVID-19. Lancet Child Adolesc Health,2020 ; 4(5), 347-
2. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. 349. doi:10.1016/S2352-4642(20)30096-1.
Immediate Psychological Responses and Associated 10. Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX,
Factors during the Initial Stage of the 2019 Coronavirus et al. The mental health of medical workers in Wuhan,
Disease (COVID-19) Epidemic among the General China dealing with the 2019 novel coronavirus. Lancet
Population in China. Int J Environ Res Public Health, Psychiatry, 2020; 7(3), e14. doi:10.1016/S2215-0366
2020;17(5). pii: E1729 doi:10.3390/ijerph17051729. (20)30047-X.
CLIPPINGS

Aerosol emission and super emission during human speech increase with voice loudness.
It is well known that coughing and sneezing are dramatic expiratory events that yield both easily visible droplets and
invisible aerosols. Nonetheless, it has long been known that normal speech also yields large quantities of particles
that are too small to see by eye, but are large enough to carry a variety of communicable respiratory pathogens.
Here, the authors show that the rate of particle emission during normal human speech is positively correlated with the
loudness (amplitude) of vocalization, ranging from approximately 1 to 50 particles per second (0.06 to 3 particles per
cm3) for low to high amplitudes, regardless of the language spoken (English, Spanish, Mandarin or Arabic).
Furthermore, a small fraction of individuals behave as “speech super emitters,” consistently releasing an order of
magnitude more particles than their peers. Our data demonstrate that the phenomenon of speech super emission
cannot be fully explained either by the phonic structures or the amplitude of the speech. These results suggest that
other unknown physiological factors, varying dramatically among individuals, could affect the probability of respiratory
infectious disease transmission and also help explain the existence of super spreaders who are disproportionately
responsible for outbreaks of airborne infectious disease.
Asadi S, Wexler AS, Cappa CD, Barreda S, Bouvier NM, Ristenpart WD. Aerosol emission and super emission
during human speech increase with voice loudness. Sci Rep 9, 2348 (2019). https://doi.org/10.1038/s41598-019-
38808-z. Accessed on 11th June, 2020.
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Indian Journal of Practical Pediatrics 2020;22(2) : 214

COVID - 19

SOCIAL EFFECTS OF COVID-19 immunization program in India, even though the clear data
PANDEMIC ON CHILDREN IN INDIA is not yet available

*Jeeson C Unni COVID-19 and children with special needs

in India
Abstract: India as a country is completing more than two
months of a nation wide lockdown, of course with different The department of empowerment of persons with
intensity. Impact of COVID-19 on child population is disability (under the Ministry of Social Justice and Welfare)
manifold. In addition to the disease related health issues, has recently released comprehensive disability inclusive
it has caused damage in various sectors of life - economic, guidelines for protection and safety of persons with
social, cultural and behavioural aspects. Children have disabilities during COVID-19.4 There is a lack of support
equally faced the impact caused by the corona virus and mentioned for educational services - distance, open or home
subsequent lock down. COVID-19 has put both lives and based. The Ministry of Human Resources Development
livelihood at stake. Though children are affected (MHRD), through its department of school literacy and
considerably less than the adults both in number and education is proactive in ensuring access to education
severity, they are very vulnerable to the non-health related through various online platforms and initiatives like
impacts of this pandemic. From delay or missing of routine e-Pathshala, National Repository of Open Educational
immunizations to more graver issues like child abuse and Resources (NROER), Digital Infrastructure for Knowledge
food insecurity, children from vulnerable sections of the Sharing (DIKSHA), SWAYAM platforms (including DTH
society face a hoard of problems. This article deals with channels), etc. to enable online learning for children.
the social impact of the pandemic in children. It does not mention the number of special children those
would benefit or how effective these programmes would
Keywords: COVID-19, Social impacts, Children. be in catering to their precise needs.5 A pandemic which
mandates social distancing and quarantine has increased
Effects of defaulting on routine
complexities for parents of children with disabilities.
immunizations
These children, used to structured schedule and learning
The Ebola epidemic has some lessons for us regarding environments have to cope up with the change.
the effect on routine immunization services and its impact.
Effect of COVID-19 on routine non-COVID
Immunization coverage decreased more than 25 % during
emergencies
the epidemic of Ebola in West Africa during 2016 as health
system was disrupted during the measures to contain the In the anxiety and fear of pandemics, many parents
epidemic.1 According to the UNICEF report, while about are reluctant to bring their children to hospital.
2000 people died of Ebola outbreak in the Democratic Common emergencies like typhoid fever, dengue, status
Republic of Congo, double of that number died of measles epilepticus, surgical emergencies like torsion testis get
in 2019 as immunization services were affected. 2 delayed treatment. Considering the risk of transmission of
The Ministry of home affairs, Governmentt of India infection, many hospitalized children underwent RT PCR
guidelines dated April 15, 2020 stated that essential medical for COVID. Surgeons are also conscious about the fact
services had to be maintained during the lockdown and it that intussusception and acute abdomen are one of the
included immunization as an essential medical service.3 presentation of COVID in children.
There is a definite reduction in the delivery of the universal
Effects of the pandemic on child and
* Editor-in-chief, adolescent psyche
IAP Drug Formulary and
Senior Associate Consultant in Pediatrics, Children are being exposed to an information overload
Aster Medcity, Kochi. and often horrifying news of the effects of the pandemic.6
email: jeeson1955@gmail.com They are witnessing high levels of stress and anxiety among
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Indian Journal of Practical Pediatrics 2020;22(2) : 215

the adults around them. Experiences of the new routine of measures to formulate a database of these children, so as
staying cooped up at home; unable to frequent places they to link them to various government social schemes and
have enjoyed, meet friends, play and engage in activities prevent them from coming out on the streets again.11
that they enjoyed, have created a sense of insecurity in
children even as young as 2 years of age.7 Therefore, Children of migrant labourers
listening to what children believe about COVID-19 is The exodus of migrants from our cities has raised
essential; providing children with an accurate explanation serious concerns. Children of migrant families are an
that is meaningful to them will ensure that they do not feel invisible vulnerable population and may include the
unnecessarily frightened, overanxious or guilty. following groups. The first group consists of children left
behind in the villages by parents who undertake
Families of children with child sexual abuse
employment elsewhere. They are dependent on remittances
A recent study by the Aarambh India Initiative of sent back home. The reduction or elimination of parent’s
NGO, Prerana and ADM Capital Foundation, has found wages due to the lockdown will have immediate effects on
that the lockdown due to the novel coronavirus outbreak food intake and health outcomes of these children.
has greatly added to the woes of families of child sexual The second group are those children who migrate with their
abuse survivors in Mumbai.8 The NGO interviewed parents who are often engaged in the construction sector,
127 families with whom it is presently associated, most of brick kilns and agricultural sectors. A study on informal
them being from the underprivileged sections of society. worksites in seven Indian cities, revealed that 80% of the
The researchers feel that for many families, the challenges accompanying migrant children did not have access to
of dealing with the aftermath of child sexual abuse have education, 30% never enrolled in schools and 90% did not
been compounded by a sudden loss of income and a lack access ICDS services.12 Almost all children were found to
of social support. be living in hazardous and unhygienic conditions.
The job losses encountered by the migrant workers in the
A pandemic within a pandemic - the silent pandemic current pandemic will only worsen the plight of these
of child sexual abuse is a reality. Vikas Puthran of Childline children. Thousands of these families left to their native
India Foundation (CIF) reported that in 10 days of the places with infants and toddlers in tow, either by foot or
lockdown - between 20 and 31 March, there was a 50% transport arranged by state governments, exposing these
increase in the number calls to 3 lakh as compared to children to unforeseen problems of hunger and illnesses.
2 lakh.9 It was noted that since a significant number of The third group is children who migrate for employment.
abusers, especially in cases of incest, the sexual Child rights activists have noted a range of issues ranging
involvement with children is situational and occurs as a from loss of wages and physical abuse. Relief and transit
result of life stresses - lockdown was perfect environment camps in state borders as well as quarantine facilities should
for an increase in sexual abuse. Additionally, self- arrange safe and child friendly shelters that provide
quarantining at home means being in continuous and close nutritious food, water and sanitation for families.
proximity with one’s abuser; which can be extremely
emotionally taxing.10 Telemedicine during the COVID-19 pandemic

Street children in India There is an immense role for tele-consultation in out-

patient, in-patient and ICU care.13 The Ministry of Health
Tens of thousands are calling help lines daily while and Family Welfare (MoHFW), in collaboration with NITI
thousands are going to bed hungry as the country shuts Aayog and Board of Governors (BoG), Medical Council
down to battle the pandemic. India has a large number of of India (MCI) have approved guidelines involving all
children who work as rag-pickers in cities or sell balloons, channels of communication with the patient that leverage
pens and other knick-knacks at traffic lights - these millions information technology platforms, including voice, audio,
live in cities - on streets, under flyovers, or in narrow lanes text and digital data exchange and most importantly
and bylanes. During the lockdown everyone has been told allowed doctors to prescribe medicines.14 The government
to stay home. But what about the street children? has also listed out certain drugs that cannot be prescribed
Where do they go? According to one estimate, Delhi has through telemedicine. This includes drugs listed under
more than 70,000 street children - may be much higher. Schedule X of Drugs and Cosmetics Act and Rules and
Taking note of the plight of street children during the any Narcotics and psychotropic substance listed
coronavirus lockdown, the National Commission for in the Narcotics Drugs and Psychotropic Substances
Protection of Child Rights (NCPCR) has suggested Act of 1985.

103
Indian Journal of Practical Pediatrics 2020;22(2) : 216

Conclusion persons with Disabilities (Divyangjan) in light of

COVID-19. https://pib.gov.in/Press Release Page.aspx?
Some of the issues that India is facing are highlighted. PRID= 1608495. 2020; Mar 27. Accessed 8th May, 2020.
Many more will surface as we live through this pandemic. 5. Pandey P, Srivastava S. Excluding the excluded: India’s
We need to be better prepared for a grim future ahead - response to the education of children with disabilities
health budgets, health infrastructure, improving during COVID-19. https://timesofindia.indiatimes.com/
telemedicine facility, disaster management drills and drastic blogs/voices/excluding-the-excluded-indias-response-to-
change in lifestyle and travel behavior need to be the-education-of-children-with-disabilities-during-
inculcated. covid-19/ April 26, 2020.
6. Danese A, Smith P, Chitsabesan P, Dubicka B. Child and
Points to Remember adolescent mental health amidst emergencies and disasters.
Br J Psychiatry 2020; 216(3):159-162.
• The social impact of the corona pandemic on
7. Dalton L, Rapa E, Ziebland S, Rochat T, Kelly B,
children and young people in particular may be
HaningtonL, et al. Communication Expert Group.
significant. Communication with children and adolescents about the
• Defaulting on routine immunization due to lockdown diagnosis of a life-threatening condition in their parent.
can lead to outbreaks of vaccine preventable diseases. Lancet 2019; 393: 1164-1176.
8. Pandharipande N. Coronavirus Outbreak: For families of
• Government has introduced several e - platforms for child sexual abuse survivors, lockdown makes dealing with
making education accessible to children, but these trauma much more difficult. https://www.firstpost.com/
may not be uniformly available to children with india/coronavirus-outbreak-for-families-of-child-sexual-
special needs. abuse-survivors-lockdown-makes-dealing-with-
trauma-much-more-difficult-8277121.html. Accessed
• Access to management of chronic and acute medical/
7th May, 2020.
surgical non COVID conditions is also hampered.
9. Buckshee D. Child Abuse , Pornography on the Rise in
• Psychological impact of the pandemic on child and India’s COVID-19 Lockdown? https://fit.thequint.com/
adolescent psyche cannot be undermined. coronavirus/is-child-abuse-on-the-rise-in-indias-covid-19-
lockdown. Accessed 7th May, 2020.
• Significant increase in child abuse has been reported.
10. Green P. National Network of Designated Healthcare
• Street children and children of migrant labourers Professionals for Children, Children’s Department,
are exposed to significant challenges in food security St George’s University Hospital, London, UK.
and health. Risks to children and young people during COVID-19
pandemic a shift in focus is needed to avoid an
• Telemedicine should be more efficiently utilized irreversible scarring of a generation. Br Med J 2020;
during pandemics. 369:m1669 doi: 10.1136/bmj.m1669. Accessed on
References 23rd May, 2020.
11. COVID-19 Lockdown: NCPCR To Focus On Creating
1. Sun X, Samba TT, Yao J, Yin W, Xiao L, Liu F, et al. Database Of Street Children. Press Trust of India.https://
Impact of the Ebola outbreak on routine immunization in www.republicworld.com/india-news/general-news/
western area, Sierra Leone- a field survey from an Ebola covid-19-lockdown-ncpcr-to-focus-on-creating-database-
epidemic area. BMC public Health. 2017; 17:363-369. of-street-children.html Accessed 8th May, 2020.
2. Measles claims more than twice as many lives than Ebola 12. From: Behera R, DnielU, Minz R. Young lives at worksite.
in DR Congo. UN News. Global perspective Human The invisible children. 19 - 30. Eds. India. MiRC, Aide-
stories. https://news.un.org/en/story/2019/11/1052321. et-Action. 2014.
Accessed 7th May, 2020. 13. Lurie N, Carr BG. The role of telehealth in the medical
3. Revised Consolidated Guidelines of Ministry of Home response to disasters. JAMA Intern Med. 2018; 178:745-
Affairs. Ministry of Information & Broadcasting. Available 746.
from: https://pib.gov.in/Press Release Page.aspx? 14. Ministry of Health and Family Welfare in in partnership
PRID=1614611. Accessed on 23rd May, 2020. with NITI Aayog. Telemedicine Practice Guidelines
4. Ministry of Social Justice & Empowerment. Enabling Registered Medical Practitioners to Provide
Comprehensive Disability Inclusive Guidelines. Healthcare Using Telemedicine. March 25, 2020.
DEPwD issues comprehensive disability inclusive https://www.mohfw.gov.in/pdf/Telemedicine.pdf.
guidelines to States/UTs for protection and safety of Accessed on 10th May, 2020.

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Indian Journal of Practical Pediatrics 2020;22(2) : 217

COVID - 19

PREPAREDNESS FOR REOPENING AND school closure worldwide. One hundred and eighty six
CONDUCT OF SCHOOLS DURING AND countries have implemented nationwide closures with
POST COVID-19 PERIOD another eight countries implementing local closures.1
The Indian system of education was left perplexed when
*Narmada S the much awaited public exams and other competitive
**Somasundaram A examinations had to be postponed or cancelled. Given the
uncertain trajectory of this pandemic, there is confusion
Abstract: COVID-19 has thrown the educational system
among students and school authorities of how the upcoming
of India into turmoil. India with its vast and diverse
academic year will be. In addition to this, it is difficult to
educational scenario has to prepare itself for reopening
predict the impact on children of the extended absence from
and conducting schools, taking into account the disparity
regular school. India with its 15 lakh schools and 50,000
in the economic strata among its institutions. Schools serve
higher educational institutions is home to one of the most
as nodal centres for distribution of nutritious food, for
diverse and largest educational system in the world.2,3
physical fitness and also take care of psychosocial
The system here is unique, in that we have government
wellbeing of the children. Hence, closure of schools causes
schools with minimal infrastructure and international
multidimensional effects. Lack of space, resource
schools with the best possible infrastructure, existing under
constraints, disparity in accessing technological
the same boards. The following article focuses on the issues
advancements are huge challenges in implementing
faced by the schools in India and the measures to be
uniform policies while reopening. The introduction of new
implemented during and post COVID period.
online and offline platforms of education by the efforts of
government has paved the way for a new learning Impact of COVID-19 on schools - the Indian
methodology. This combined with additional efforts to take scenario
care of the nutritional and physical needs of the children
will usher in a different era in Indian educational system. India ordered closure of the schools and colleges on
This article discusses policies that can be implemented by 16th March 2020. This is a crucial time for our education
schools with the support and willingness of all stake holders sector as board examinations, entrance to various
from the students to the society at large. The methods and universities, competitive examinations were all set to
need to implement principles of social distancing, happen during this period. The new academic year also
respiratory hygiene and etiquette, minimising large starts by June. Around 32 crore young learners in India
gatherings, restructuring of seating arrangements, self- have been impacted and the most severe among them, are
discipline in reporting and treatment of illnesses are approximately 13 crore students in classes 9 to 12.
discussed. The resultant impact on the students are :

Keywords: Educational system, India, COVID-19 impact, 1. Interrupted learning

Reopening schools. 2. Poor nutrition - mid day noon meal scheme providing
significant proteins and calories is unavailable
Nobody would have expected a scenario where a tiny
virus would shake the entire world. As of 27th April 2020, 3. Confusion and stress for parents and teachers
approximately 1.725 billion learners are affected due to 4. Challenges of e-learning and home schooling
* Consultant Pediatrician & Director, 5. Gaps in child care and high economic burden for
Nalam Medical Centre & Hospital, Vellore. parents
** Consultant in Child Development and Behaviour.
D’Soul Child Development Centre & KKCTH, 6. Rising exposure to child pornography, sexual
Chennai. exploitation and domestic violence
email : dr.narmadhaashok@gmail.com 7. Social isolation4
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Indian Journal of Practical Pediatrics 2020;22(2) : 218

Unique challenges of Indian educational 3. Regular screening and management of symptomatic

system students, teachers and other school staff
Indian education system has 70% of students in 4. Communication with parents and students
government institutions with minimal access to online 5. Additional school-related measures
system of education. 5 The considerable gap in the
infrastructure between government and private schools and 6. Regulations to be followed in Residential schools11
the domestic environments of students is a huge challenge. 1. Hygiene and environmental cleaning to limit exposure
The main issue is the space constraint in schools. a) Educate everyone in the school about COVID-19 with
The average work area a student gets in India is only emphasis on its prevention; this includes appropriate and
2 feet. With an average student’s shoulder width of 2 feet, frequent hand hygiene, respiratory hygiene, mask use,
even in the most elite of schools, children are made to sit symptoms of COVID-19 and what to do if one gets sick.
very close to each other. Some classes cater to Non-contact greetings should also be advised.
around 150 students which means they are in close Weekly updates must be provided as the pandemic evolves.
proximity to each other. Almost 45% of schools lack
playgrounds.6 b) Create a schedule for frequent hand hygiene, especially
for young children, and provide sufficient alcohol-based
With schools shut down, remote learning is the only rub or soap and clean water at school entrances and
way available. However, the major challenge in India is throughout the school. Hand washing strategies include
the access to electricity and internet connections. A nation- washing with soap and water for at least 20 seconds,
wide survey of villages done in 2017-18 showed that though especially after using the toilet, before eating, after blowing
99.9% of homes had access to power connection, 53% of their nose, coughing or sneezing. Where feasible, using an
the houses did not have electricity for upto 12 hours in a alcohol-based hand sanitizer that contains at least 60%
day. Only 24% of Indians had access to smart phones and alcohol can be encouraged where water is scarce.12
hardly 11% of households had access to any form of smart
devices like net books, palmtops, desktops or tablets. c) Schedule regular cleaning of the school environment,
Besides, there are interstate variations in the availability including toilets, with water and soap/detergent and
of the electricity and internet.7 disinfectant. Clean and disinfect frequently touched
surfaces such as door handles, desks, toys, supplies, light
The other issue is the nutritional needs of the children.
switches, doorframes, play equipment, teaching aids used
There is now a logistic challenge in providing food for
by children and covers of books.
nearly 12 crore children who are dependent on the midday
meal, which is probably the only nutritious meal they get. d) Limiting the timing of exposure or direct physical contact
On the other hand, there is a growing incidence of obesity is mandatory like in physical education classes, sports or
from 3.6 to 11.7% among affluent school students.8,9 other physical activities and play in playgrounds, wet areas
We are at the crossroads where the double challenge of and changing rooms. Can avoid contact sports/swimming
obesity and undernutrition have to be addressed. classes and encourage alternate methods of individual sport
In the following sections, we would discuss the activities.
measures to be adopted by various stakeholders, keeping e) Increase frequency of cleaning in gym, sports facilities
in mind the unique challenges of the Indian education and in changing rooms, provide hand hygiene stations at
system. entrances and exits, establish one-way circulation of
Measures to be adopted by the school students through the facilities and limit the number of
administration persons allowed in the locker room at one time.

When schools are fully or partially open, COVID-19 f) Put in place respiratory and hand hygiene and physical
prevention and control strategies should be maintained. distancing measures in transportation such as school buses
The recommended actions and requirements outlined in and tips for students on safe commute to and from school,
the following section are simple and can be adopted in all including those using public transport. Allow only 1 child
schools irrespective of the economic discrepancies.10 per seat and at least 1 metre apart in school buses, if
possible. This may lead to a need to increase the number
1. Hygiene and environmental cleaning to limit exposure of school buses per school. If possible, windows of the
2. Physical distancing at school bus should be kept open.
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Indian Journal of Practical Pediatrics 2020;22(2) : 219

g) Develop a school policy on wearing a mask or a face house, a favourite restaurant, a birthday party or the local
covering in line with national or local guidance. If a child shopping mall.14
or school staff is sick, she/he should not come to school.
3. Screening and management of sick students, teachers
Provide sufficient medical masks for those who need it,
and other school staff
such as school nurses and children with symptoms.
a) Enforce the policy of “staying at home if unwell” for
2. Physical distancing at school: Measures given here students, teachers or school staff with symptoms.
also addresses the issues of spacing in schools especially
staggering the opening hours and modification of timetable. b) Create a checklist for parents/students /staff to decide
whether students /staff can go to school taking into
a) Maintain a distance of at least 1 metre between everyone consideration the local epidemiology of COVID-19.
present at school. The checklist could include:
b) Increase desk spacing (at least 1 metre between desks), • underlying medical conditions and vulnerabilities,
putting dividers in between desks, altering the arrangements to protect the student/staff
like a circular class room, staggering recesses/breaks and
• recent illness or symptoms suggestive of COVID-19,
lunch breaks (if difficult, an alternative is to have lunch at
to prevent spread to others
the desk).
• special circumstances in the home environment,
c) Modify the timetable, with some students and teachers to tailor support as needed
attending in the morning session and others in the afternoon
session. Another alternative is to have half the students • special considerations regarding school transport as
attending on 3 days of a week and the other half on the needed.
other 3 days {odd-even plan}.13 c) Consider daily screening for body temperature, and
d) Consider increasing the number of teachers, if possible, history of fever or ‘feeling feverish’ in the previous
to allow for fewer students per classroom (if space is 24 hours, on entry into the building for all staff, students
available). and visitors to identify persons who are sick. Ensure that
enough personnel are available for this screening.
e) Advise against crowding during school pick-up or day
d) Ensure students who have been in contact with a
care and if possible, avoid pick up by older family or
COVID-19 case stay at home for 14 days. The school
community members (e.g. grandparents) and stagger arrival
officials should notify public health authorities in case of
and/or dismissal times.
a positive COVID-19 case.
f) Move lessons outdoors or ventilate rooms as much as e) Establish procedures for students or staff who have
possible (and try to avoid use of air conditioners, especially symptoms of COVID-19 or are feeling unwell in any way
central type). to be sent home or isolated from others.
g) Create awareness to ensure the students do not gather 4. Communication with parents and students
and socialize when leaving the school and in their free
time. a) Inform parents about the measures the school is putting
in place and ask for cooperation to report any cases of
h) Cancel field trips, assemblies and other large gatherings. COVID-19 that occur in the household. If someone in the
household is suspected to have COVID-19, keep the child
i) Limit nonessential visitors and reduce congestion in the
at home and inform the school.
office.
b) Explain to the students the reason for school-related
j) Limit bringing in students from other schools for special measures, including discussing the scientific considerations
programs (e.g., music, robotics, academic clubs) and highlighting the help they can get through schools
k) Parent teacher meetings can be restructured via phone (e.g. psychosocial support).
rather than face-to-face, enabling easier communication 5. Additional school-related measures
both ways.
Ensure that during school entry, all age appropriate
l) Discourage staff, students and their families from vaccinations especially those against vaccine preventable
gathering or socializing anywhere at places like a friend’s diseases are completed.
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Indian Journal of Practical Pediatrics 2020;22(2) : 220

6. Regulations to be followed in residential schools 6. Age appropriate technique to be adopted - For e.g.
The kindergarten schools can be close. If open, pre-
Most of the policies discussed above will also be schoolers can be taught all these etiquettes with simple
applicable for boarding schools. The following are some rhymes and manoeuvres like flapping their wings or
of the policies specific for Residential school extending their arms to instill the concept of safe distance.
a. It is imperative that the students are screened on arrival 7. E- learning - Children should be encouraged to adapt
to the hostel to this new method of learning, to have their doubts clarified
b. There is a need to have an inhouse nurse and if students and supported.12
are more to have an inhouse doctor on call Role of parents and care givers
c. Students to be encouraged to report even if there are Parents and caregivers have seldom spent so much
minor health related complaints
time with children as during this pandemic, therefore
d. Seperate facilities or local guest houses to isolate children this is a unique opportunity to mould their children’s
or staffs who turn out to be positive with minor symptoms behaviour. With no other diversions or people to
need to be prepared in advance. distract them and with so much uncertainties around,
e. Cleaning of the exposed areas according to government parents’ presence and their psychological support is
protocols should be followed - Close and Clean response.15 essential to all children from pre-schoolers to
adolescents.
Measures to be adopted by the students
1. It is of utmost importance for parents to update
1. Learning the steps for hand washing themselves on the latest facts from reliable sources about
COVID-19. They should take care not to share inaccurate
It is mandatory that every student learns the techniques
information or videos regarding the negative aspects of
of hand washing which should be done on school entry,
illness.
before and after food and snacks and after using the rest
rooms. Remember not to touch the face. 2. They need to recognise symptoms of COVID-19 like
fever, cough, sore throat or shortness of breath and seek
2. Maintaining social distance in the school
immediate medical attention. They need to notify the school
They need to maintain their designated places with and also reassure their child in simple language.
1 metre distance between friends, avoid touching each other Unnecessary panic by the parents will further frighten the
during free time and avoid sharing cups, eating utensils, children.
food or water bottles.
3. Encourage the children to attend school when they are
3. Training the children to be leaders in keeping healthy.
themselves, their school, family and community healthy
4. It is their responsibility to reinforce basics of hand
They need to learn about preventing disease spread washing, cough etiquette and social distancing .12
and model good practices such as sneezing and coughing
5. Parents should be supportive to their children in their
into elbows.
efforts to attend classes online. Make provisions at home
4. Learn to accept other children who return after to install gadgets and monitor their use by their children.
recovering from illness Many NGOs are ready to help with distance learning.
Pooling of resources in the community to help less fortunate
Children should be taught to accept others and not students in the area can also be initiated by parents.
tease anyone since everybody is prone to the infection.
6. It is the duty of the parents to ensure a child friendly and
5. Should learn to immediately contact the caregiver if calm environment to facilitate learning at home as school
they feel slightly sick timings may change allowing the children to do their work
Children should be encouraged to seek the help of the predominantly through e-learning.
caregiver if they feel sick and should be supported 7. Domestic violence to be strictly condemned as it is the
psychologically so that they are not frightened by their right of every child to have a safe environment at school
sickness. or home.
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Indian Journal of Practical Pediatrics 2020;22(2) : 221

Future of education New laws to maintain online privacy of

children
This pandemic will change the course of education as
we know it. We need to teach the guardians of tomorrow, While online platforms are being developed,
resilience, adaptability, communication, empathy, commitment to protect the privacy of children should be a
creativity, emotional intelligence and other life skills for top priority and all stake holders especially vendors need
the future. Theory based learning should give way to to be covered by the law.11 Children’s Online Privacy
experiential learning, taking greater recourse to technology. Protection Act (COPPA) adopted now in USA may have
Schools need to keep these challenges in mind while to be integrated in India too.
designing the curriculum. Government schools have
New system of arrangements of classes
commenced smart classes and Montessori system of
learning and in due course will learn to keep pace with With greater space constraint, effective and efficient
these changes.16 ways of conducting classes have to be devised. We need to
do away with traditional bench system of seating and use
New systems of learning alternative type of seating like a circle, or running school
in shift systems.
We need content and delivery systems that harness
and utilize technology to its fullest. Looking at these Future modalities to maintain physical
challenges of colleges and schools, various initiatives have fitness
come up from the Ministry of Human Resources,
Department of Technical Education, National council of Opening up of other avenues for physical fitness
educational research and training (NCERT) and NGOs. becomes essential. Starting of online yoga instructions and
short physical education videos for students of all ages
Some of the new initiatives are Swayam - online may be a viable alternative. The portal needs to integrate
courses for teachers, UG/PG teachers for non technology social/ club virtual hangouts and online school
courses, e-modules on various subjects. National digital counselling.11
library, google classroom and e-Yantra are other resources.
Swayam portal integrates NCERT textbooks, engineering Adopting new ways to deliver and maintain
and non-engineering courses and e-books for students. nutrition of children
It is a viable alternative and easy learning to grasp the Unfortunately India would be one of the 88 countries
course. The portal was set up by Government of India nearly to miss its nutrition related target of reducing stunting in
two and a half years ago and it definitely endorses the fact children. India is identified as among the three worst
that e-learning may not be a distant dream.17 countries, along with Nigeria and Indonesia, for wide,
within-country disparities on stunting, where the levels
Government has created National Knowledge
varied four-fold across communities. It is imperative that
Network, National Project on Technology Enhanced
alternate system to maintain nutrition is facilitated even if
Learning (NPTEL), National Mission on Education
children stay at home due to new modes of learning.
Through Information and Communication Technology
This can include delivery of foods to their homes using
(NMEICT). These connect easily with institutions and
public distribution system, making available nutritious
provide the high speed band network for education
powders for collection at the school and provision of cash
institutes.
or vouchers.18,19
Efforts need to be made by all of us to make sure PC/ Conclusion
Desktop/ Mobile for end delivery are available to every
student irrespective of the strata of society. Giving away In conclusion, a joint effort by all stake holders from
laptops to all students studying in 11 th standard and the management of schools, parents, students, government
above in Tamilnadu is an example which shows us that and NGOs have a great part in preparing the schools to
this is feasible.2 Future of education is going to be global handle the post COVID situation. Future of our younger
teachers, global university, degrees obtainable from reputed generation will be protected by our willingness to bring in
universities offering interesting distant learning content and changes in the system that not only raises them to be
a global outlook. Faculty will also need to stand up to this responsible individuals, but also fosters a responsible
challenge of integrating technology in their teaching. community that appreciates and protects nature and
Accreditation criteria need reconsideration. nurtures posterity.
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Indian Journal of Practical Pediatrics 2020;22(2) : 222

Points to Remember Available from: https://scroll.in/article/960939/indian-

• COVID-19 has disrupted India’s educational system education-cant-go-online-only-8-of-homes-with-school-
children-have-computer-with-net-link.
which is vast and varied with wide disparity in
8. Midday Meal Scheme. In: Wikipedia [Internet]. 2020 [cited
resources amongst the schools in the public and
2020 May 10]. Available from: https://en.wikipedia.org/w
private sector. index.php?title=Midday_Meal_Scheme&oldid=955148909.
• Schools are not only centres of education in India 9. Sashindran VK, Dudeja P. Obesity in School Children in
but take care of nutritional and physical needs of India. Public Health in Developing Countries - Challenges
children through various schemes. and Opportunities [Internet]. 2020 Jan 30 [cited 2020
• Schools need to implement uniform policy to May 10]; Available from: https://www.intechopen.com/
online-first/obesity-in-school-children-in-india.
maintain social distancing, respiratory etiquette as
10. Considerations for school-related public health measures
well as usher in new modalities of education for the in the context of COVID-19 [Internet]. [cited 2020 May
coming years. 19]. Available from: https://www.who.int/publications-
• The future of the education system will involve more detail/considerations-for-school-related-public-health-
of e-learning platforms with policies to maintain the measures-in-the-context-of-covid-19.
privacy of children and newer modalities to take care 11. NAIS - Coronavirus (COVID-19) Guidance for Schools
of nutrition and fitness with significant changes in [Internet]. [cited 2020 May 3]. Available from: https://
infrastructure. www.nais.org/articles/pages/additional-covid-19-
guidance-for-schools/.
References 12. https://www.who.int/docs/default-source/coronaviruse/
1. Impact of the COVID-19 pandemic on education. key-messages-and-actions-for-covid-19-prevention-and-
In: Wikipedia [Internet]. 2020 [cited 2020 May 10]. control-in-schools-march-2020.
Available from: https://en.wikipedia.org/w index.php? 13. Schools reopening News: Schools may go for odd-even
title=Impact_ of_the_covid-19_pandemic_ on_ education system post lockdown [Internet]. [cited 2020 May 19].
&oldid= 955684360. Available from: https://www.timesnownews.com/
2. www.ETGovernment.com. COVID-19 Pandemic: Impact education/article/schools-reopening-news-schools-may-
and strategies for education sector in India - ET go-for-odd-even-plan-post-lockdown/588705.
Government [Internet]. ETGovernment.com. [cited 2020 14. CDC. Coronavirus Disease 2019 (COVID-19) [Internet].
May 3]. Available from: https://government. Centers for Disease Control and Prevention. 2020 [cited
economictimes.indiatimes.com/news/education/covid-19- 2020 May 3]. Available from: https://www.cdc.gov/
pandemic-impact-and-strategies-for-education-sector-in- coronavirus/2019-ncov/community/reopen-guidance.html
india/75173099. 15. NAIS - Coronavirus (COVID-19) Guidance for Schools
3. Sharma K. In India, over 32 crore students hit by [Internet]. [cited 2020 May 3]. Available from: https://
COVID-19 as schools and colleges are shut: UNESCO www.nais.org/articles/pages/additional-covid-19-
[Internet]. The Print. 2020 [cited 2020 May 10]. Available guidance-for-schools/#boarding.
from: https://theprint.in/india/education/in-india-over-32- 16. Delhi May 4 ITWDN, May 4 2020 UPDATED:, Ist 2020
crore-students-hit-by-covid-19-as-schools-and-colleges- 18:36. COVID-19 lockdown: How the pandemic bringing
are-shut-unesco/402889/. change in Indian education system [Internet]. India Today.
4. h t t p s : / / p l u s . g o o g l e . c o m / + U N E S C O . A d v e r s e [cited 2020 May 13]. Available from: https://
consequences of school closures [Internet]. UNESCO. www.indiatoday.in/education-today/featurephilia/story/
2020 [cited 2020 May 10]. Available from: https:// covid-19-lockdown-how-the-pandemic-brining-change-in-
en.unesco.org/covid19/educationresponse/consequences. indian-education-system-1674322-2020-05-04.
5. Khanna PKN Pretika. Every house a school, every parent 17. Amidst COVID-19, an air of change in the Indian education
a teacher as COVID-19 impacts education [Internet]. system [Internet]. Express Computer. 2020 [cited 2020
Livemint. 2020 [cited 2020 May 10]. Available from: May 13]. Available from: https://www.expresscomputer.in/
https://www.livemint.com/news/india/every-house-a- news/amidst-covid-19-an-air-of-change-in-the-indian-
school-every-parent-a-teacher-as-covid-19-impacts- education-system/52699/
education-11585140662556.html. 18. India may miss nutrition targets. The Hindu [Internet].
6. S B. Ministry relaxes rules on play space requirements 2020 May 12 [cited 2020 May 13]; Available from: https:/
under RTE. The Hindu [Internet]. 2012 Dec 2 [cited 2020 /www.thehindu.com/news/national/india-may-miss-
May 17]; Available from: https://www.thehindu.com/news/ nutrition-targets/article31568549.ece.
national/karnataka/ministry-relaxes-rules-on-play-space- 19. 320 million children worldwide missing out on meals due
requirements-under-rte/article4154277.ece. to COVID-19: WFP [Internet]. [cited 2020 May 13].
7. Kundu P. Indian education can’t go online - only 8% of Available from: https://www.downtoearth.org.in/news/
homes with young members have computer with net link food/320-million-children-worldwide-missing-out-on-
[Internet]. Scroll.in. https://scroll.in; [cited 2020 May 10]. meals-due-to-covid-19-wfp-69976.
110
Indian Journal of Practical Pediatrics 2020;22(2) : 223

COVID - 19

GUIDELINES FOR HANDLING DEAD Box 1. Handling dead bodies of COVID-19

BODY OF A COVID-19 PATIENT Standard precautions
*Lakshmi S i. Hand hygiene.
**Kalpana S
ii. Use of personal protective equipment (e.g. water
Abstract: As the number of positive cases for the novel resistant apron, gloves, masks, eyewear, shoe covers).
Coronavirus continues to increase, so do the deaths iii. Safe handling of sharps.
associated with it. There exists a theoretical risk of infection
during handling of the dead bodies and standard infection iv. Disinfect the instruments and devices used on the
control practices should be followed when handling such patient, after disposing the dead body.
bodies. The government has allowed both the burial and v. Disinfect linen, clean and disinfect environmental
cremation as per the faith. However there is a standard surfaces
procedure that all health workers and family members need
to adhere to. This article highlights some of the guidelines longer. Due to the congealing of respiratory secretions and
recommended for managing dead bodies of COVID-19 rapid destruction of the virus when not sustained by live
patients. tissues, residual hazard from body fluid spillage will not
present a risk. However WHO recommends transporting a
Keywords: Handling dead body, COVID-19, Children. body with acute respiratory infection by applying a face
mask and sealing in an impermeable body bag before
There is likely to be a continuing risk of infection being removed from the isolation area to avoid leakage of
from the body fluids and tissues of patients who have died body fluid.
of severe acute respiratory syndrome-Corona virus2
(SARS-CoV-2) infection. After death, their bodies should Standard precautions are to be followed by health care
be treated with sensitivity, dignity and respect, at the same workers while handling dead bodies of COVID-19
time taking due precautions to protect persons in proximity (Box 1).
from infection. Unzipping the body bag by mortuary staff Removal of the body from the isolation room
using standard precautions may be allowed for the relatives or area
to see the deceased for one last time.
• The health worker attending to the dead body should
In actuality, there is little residual hazard of perform hand hygiene, ensure proper use of PPE (water
transmission of SARS-CoV-2 from the deceased apart from resistant apron, goggles, N95 mask, gloves).
potential droplet generation from artificial air movement • All tubes, drains and catheters on the dead body should
during the initial care of the deceased and post-mortem be removed After use, the disposable items such as
examination where power tools are used, posing a risk for gloves and protective clothing should be disposed of
aerosol generation. in a plastic bag.
It is estimated that viable virus could be present for • Any puncture holes or wounds (resulting from removal
up to 48 to 72 hours on environmental surfaces in ‘room of catheter, drains, tubes, or otherwise) should be
air’ conditioners. In dead bodies, particularly those retained disinfected with 1% hypochlorite and dressed with
at refrigeration conditions, infectious virus may persist for impermeable material.
• Caution recommended while handling sharps such as
* Professor of Pediatrics
intravenous catheters and other sharp devices.
** Assistant Professor of Pediatrics They should be disposed into a sharps container.
Institute of Child Health and Hopsital for Children,
Chennai. • Plug oral, nasal orifices of the dead body to prevent
email: lakshmivel67@yahoo.co.in leakage of body fluids.
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Indian Journal of Practical Pediatrics 2020;22(2) : 224

• If the family of the patient wishes to view the body at • Reduce aerosol generation during autopsy using
the time of removal from the isolation room or area, appropriate techniques especially while handling lung
they may be allowed to do so following the standard tissue.
precautions.
• Autopsy table to be disinfected as per standard
• Place the dead body in leak-proof plastic body bag. protocol.
The exterior of the body bag can be decontaminated
with 1% hypochlorite.The body bag can be wrapped Transportation
with a mortuary sheet or sheet provided by the family
members. • The body, secured in a body bag, exterior of which
has been decontaminated, poses no additional risk to
• The body maybe taken to mortuary. the staff transporting the dead body.
• All used/ soiled linen should be handled with standard
precautions, put in a bio-hazard bag and the outer • The personnel handling the body may follow standard
surface of the bag disinfected with hypochlorite precautions (surgical mask, gloves).
solution.
• The vehicle, after the transfer of the body to cremation/
• Used equipment should be autoclaved or burial staff,should be decontaminated with 1% sodium
decontaminated with disinfectant solutions in hypochlorite.
accordance with established infection prevention
control practices. Disinfection of isolation room / Mortuary
• All medical waste must be handled and disposed of in All surfaces of the isolation area (floors, bed, railings,
accordance with bio-medical waste management rules. side tables, IV stand, etc.,) should be wiped with 1% sodium
• The health care worker who handled the body should hypochlorite solution and allowed to air dry allowing a
remove personal protective equipment and perform contact time of 30 minutes.
hand hygiene.
Mortuary staff handling the dead body of COVID-19
• Provide counselling to the family members and respect patients must observe standard precautions like storing
their sentiments. them in cold chambers maintained at approximately 4ºC,
Autopsies on COVID-19 dead bodies disinfecting environmental surfaces, instruments and
transport trolleys with 1% hypochlorite solution and
Autopsies should be avoided. If autopsy is to be cleaning the chamber door, handles and floor with
performed for special reasons, the following infection 1% sodium hypochlorite solution after removing the body.
control practices should be adopted:
• The team should be ther heavy duty blades with blunt Embalming: Embalming of the dead body should not be
points to be used to reduce needle stick injuries. allowed.
• Only one body cavity at a time should be dissected Burial
• Unfixed organs must be held firm on the table and
People who have died from COVID-19 may be buried
sliced with a sponge – care should be taken to protect
or cremated but always conform to national and local
the hand
requirements that may dictate the handling and disposal of
• Autopsies should be performed in an adequately the remains. Family and friends may view the body after it
ventilated room, i.e. natural ventilation with at least has been prepared for burial, in accordance with customs.
160 L/s/patient air flow or negative pressure rooms They should not touch or kiss the body and should wash
with at least 12 air changes per hour. hands thoroughly with soap and water after the viewing.
• An oscillator saw with suction extraction of the bone Mourners should not take part in any rituals or practices
aerosol into a removable chamber should be used for that bring them into close contact with the body of the
sawing skull, otherwise a hand saw with a chain-mail deceased.
glove may be used Those tasked with placing the body in the grave,
• Needles should not be re-sheathed after fluid sampling on the funeral pyre etc., should wear gloves and wash hands
- needles and syringes should be placed in a sharps with soap and water after removal of the gloves once the
bucket. process is complete.
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Indian Journal of Practical Pediatrics 2020;22(2) : 225

Funeral rites Bibliography

Religious rituals such as reading from religious 1. COVID-19: Guidelines on dead body management.
scripts, sprinkling holy water and any other last rites that Government of India Ministry of Health & Family Welfare
Directorate General of Health Services (EMR Division).
do not require touching of the body can be allowed.
https://www.mohfw.gov.in/pdf/1584423700568_
Large gathering at the crematorium/ burial ground should covid-19. Guidelines on dead body management.pdf.
be avoided. A maximum of 20 people with masks may be Accessed on 2nd May 2020.
allowed to attend the funeral rites (may vary according to 2. Guidance for care of the deceased with suspected or
local guidelines). The ash does not pose any risk and can confirmed coronavirus (COVID-19). Updated 20th April
be collected to perform the last rites. 2020. Available from https://www.gov.uk/government/
publications/covid-19.guidance-for-care-of-the-deceased/
Conclusion guidance-for-care-of-the-deceased-with-suspected-or-
confirmed-coronavirus-covid-19. Accessed on 2nd May
There remains a theoretical risk of infection from
2020.
spread of virus from the body of the deceased. Nevertheless,
3. Infection prevention and control for the safe management
the usual precautions and principles of standard infection
of a dead body in the context of COVID -19. Interim
control apply for bodies that are suspected or confirmed guidance 24 th March 2020. Available from https://
to be infected with coronavirus. Precautions should be apps.who.int/iris/bitstream/handle/10665/331538/WHO-
taken at every level, starting from health care workers, covid-19-lPC_DBMgmt-2020.1-eng.pdf. Accessed on
mortuary staff, body handlers and mourners alike. 2nd May 2020.

CLIPPINGS

COVID-19 plasma therapy safe, without adverse side effects: Study done in Houston, USA in March 2020.
The clinical administration of the blood component plasma from recovered COVID-19 patients to those severely
affected by the disease could be a safe option without adverse side effects, according to a study which may lead
to better treatment protocols against novel coronavirus infection.
On March 28, researchers from the Houston Methodist Hospital in the US, began clinical trials to transfuse
plasma from recovered COVID-19 patients into critically ill patients, they noted in a statement. In the study,
published in The American Journal of Pathology, the scientists described the clinical outcomes of the convalescent
plasma transfusion trial, showing 19 out of 25 patients improving with the treatment and 11 discharged from the
hospital.
However, the study noted that a randomised clinical trial, with a large control group, is needed to validate the
findings. According to the researchers, this is the largest cohort worldwide assessed for outcomes pertaining to
convalescent plasma transfusion for COVID-19 and is the first peer-reviewed publication on convalescent plasma
use in the US.
While physician scientists around the world scrambled to test new drugs and treatments against the COVID-19
virus, convalescent serum therapy has emerged as potentially one of the most promising strategies. The scientists
noted that the century-old therapeutic approach dates back to at least as early as 1918 to fight the Spanish Flu.
Convalescent plasma therapy was used with some success during the 2003 SARS pandemic, the 2009 influenza
H1N1 pandemic and the 2015 Ebola outbreak in Africa. According to the study, the observed complications
were consistent with findings reported for COVID-19 disease progression, and did not result from the plasma
transfusions. The researchers said the study’s findings were consistent with several other small case studies of
convalescent plasma use for severe COVID-19 that have been recently reported. The limitations of the research
as a small case series and no control group was included. It is not clear if the 25 patients given convalescent
plasma would have improved without the treatment, as all patients were treated with multiple other medications,
including antiviral and anti-inflammatory agents.
Salazara E, Pereza KK, Ashrafd M, Chena J, Castilloa B, Christensena PA, et al. Treatment of COVID-19
patients with convalescent plasma. Am J Pathol. Epub ahead of print. DOI:https://doi.org/10.1016/
j.ajpath.2020.05.014.

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Indian Journal of Practical Pediatrics 2020;22(2) : 226

GENERAL ARTICLE

TELEMEDICINE - GUIDANCE FOR prevention of disease and injuries.” It can also be used for
PEDIATRIC PRACTICE research, evaluation and continuing medical education for
improving the health of individuals and their community.2
*Santosh MK In March 2020, Medical Council of India came out with
**Balachander D telemedicine practice guidelines, in partnership with
National Institution for Transforming India Commission
Abstract: Advancement in technology is a boon in disguise
(NITI Ayog).3 Though telemedicine has been in use for the
for mankind especially during this COVID-19 pandemic.
last 30 years its increasing use in the last 3-4 years
Telemedicine provides a platform whereby patients are able
especially now during the COVID-19 pandemic has the
to receive treatment even without an in-person hospital
potential to transform pediatric practice. Any pediatrician
visit. With proper care, consent and guidelines,
is entitled to provide telemedicine consultation to patients
telemedicine paves the way for a better tomorrow. At this
in any part of India upholding professional and ethical
time, it also serves to prevent spread of infection by
norms and standards. They would be required to undergo
minimizing hospital visits which is of due importance in
a mandatory online course by the Medical Council of India
the vulnerable pediatric group. This article is presented
(within 3 years of start of telemedicine) which is in the
as a guidance for the practicing pediatrician embarking
pipeline.
on teleconsultation for the first time - issues to be aware of
while prescribing and the legal aspects. Implementation
Keywords: Telemedicine, Pediatrics, Technological There are more than 50 platforms which provide
infrastructure, Optimum healthcare. telemedicine facility. One must have very good internet
connectivity and a computer/ laptop/ smart phone with
Epidemics and pandemics are challenges in providing
preferably high resolution camera. Telemedicine has
optimum healthcare for the needy. Access to health care
applications in Government, NGO and Private sector.
delivery may be hampered in such a scenario due to
For pediatricians in the private sector, a payment gateway
distance, lack of sufficient manpower, need for social
can be integrated into the platform for online payments.
distancing and time. Telemedicine is a useful tool in such
situations to provide specialized care, in responding to Irrespective of the tool of communication used, the
emergencies and providing access to pediatric care in core principles of telemedicine is the same.4 Telemedicine
remote and underserved populations. 1 Exposure to applications can be classified in to 4 basic types.
microbes during epidemics can be minimized by
telemedicine. With advancement in technological 1. Video: This gives the nearest experience to an inpatient
infrastructure on a national scale it is possible to maintain consultation and real time interaction. It is also the most
the health of children around the country without preferred tool of communication in telemedicine and is
unnecessary exposure to the infection. expected to replace other tools in the days to come.
Patient can be seen and certain signs may be identified.
Telemedicine may be defined as “The delivery of Visual cues can be perceived. Success depends on the
health care services using telecommunication technologies quality of internet connectivity at both ends and we have
for exchange of information for diagnosis, treatment and to ensure privacy of the patients. The possibility of abuse
* Consultant, or misuse should be kept in mind. Patient records and other
Department of Pediatrics and Neonatology, documentation can be stored in the cloud and or in hospital
Mission Hospital, Kannur, servers and accessed as and when required. Confidentiality
** Sr Consultant in Pediatrics, pertaining to patient treatment should be ensured.
Government General Hospital,
Pathanamthitta. 2. Audio: Audio can be carried out through mobile or land
email id: santoshnair@live.com phone. It is convenient, fast and privacy ensured.
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Indian Journal of Practical Pediatrics 2020;22(2) : 227

Real-time interaction is possible. Nonverbal cues will be 4. Availability of laboratory parameters and investigation
missed. Visuals and patient identification is not possible. results online helps the treating pediatricians.
3. Text (chat platforms and messages): It is convenient and 5. Telemedicine prevents the transmission of infection
documentation is integrated and can be real-time too. (especially hospital acquired infection) to the
May miss verbal cues, difficult to establish rapport and healthcare providers and to the patients especially
identity is questionable. during epidemics and pandemics.
4. Asynchronous (e- mail or fax): This method is more 6. Even if the consultant is not immediately available in
convenient and provides additional benefit of a tertiary institution, patient can have rapid access to
documentation. Laboratory reports, data and images can other consultants.
be easily shared, and is more useful when accompanied
with follow-ups and second opinion. This is not a real time 7. Pediatricians can offer counselling about lactation,
interaction as doctor may not see the mail immediately.5, 6 nutritional counselling and chronic care management
through telemedicine.7
A few elements have to be considered carefully before
tele-consultation. Prescribing medicine, without an 8. Pain and palliative clinics of children can utilize
appropriate diagnosis or provisional diagnosis will amount telemedicine to replace home visits. Health care
to professional misconduct. Not all medications can be providers / volunteers can visit their home with laptops
prescribed via telemedicine. The following list classifies and provide them access to the doctor and assist them
the medications and the safety with which it may be by providing vital signs of the patient and patient will
prescribed. be happy to see and communicate with his doctor.
A palliative medicine doctor can visit only 3 or 4
List 0: Very safe drugs like paracetamol, ORS solutions patients in a day. But through telemedicine he/she can
and over the counter (OTC) products. take care of up to 10 to 20 bedridden patients in
List A: Can be prescribed during first consultation which addition to their routine OPD related work.
is a video consultation. Can be prescribed again to refill Cons
during follow up. These are relatively safe drugs with low
potential for abuse like i)Ointments/Lotion for skin 1. Patient cannot be physically examined and hence more
ailments: Clotrimazole, Mupirocin, Calamine Lotion, chance for bias and errors.
Benzyl Benzoate Lotion etc, ii) Local Ophthalmological
drops such as: Ciprofloxacillin for Conjunctivitis, etc, iii) 2. Regulatory and industry barriers like which drugs can
Local Ear Drops such as: Clotrimazole ear drops, drops be prescribed and which are prohibited .
for ear wax etc. and iv) Refill medications for diabetes 3. Technical glitches may lead to interruption of
mellitus, hypertension and asthma. communication.
List B: Can prescribe add-on medications in a patient in a 4. Awareness and attitude towards telemedicine have
follow up consult for the same illness e.g., patient is already been found to be less satisfactory. Further awareness
on atenolol for hypertension and the blood pressure is not programmes are also required for patients.
controlled, an ACE inhibitor can be added such as enalapril.
5. Acceptance among healthcare professionals has not
Prohibited list: These medicines have high potential for been studied in depth.
abuse. Medicines listed in schedule X or any narcotics or
psychotropic substances. 6. Widespread implementation of telemedicine has been
a slow process due to poor organization in healthcare
Pros and cons of telemedicine
institutions.
Pros
7. Only very basic care, counselling and advice can be
1. Increases timely access to appropriate interventions. provided.
Faster access to otherwise unavailable services.
8. Cannot replace situation which require physical
2. Reduces the cost associated with travel. presence such as immunization , growth monitoring ,
3. More prompt documentation and maintenance of clinical examination, surgery and procedures like
records. dialysis.
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Indian Journal of Practical Pediatrics 2020;22(2) : 228

Reimbursement for services provided • Moreover, there are special offers from Paytm from
time to time.
For pediatricians in the private sector, a payment
gateway can be integrated into the platform for online Guidelines pertaining to hardware and
payments. Telemedicine consultations should be treated software to be used for telemedicine
the same as in-person consultations from a fee perspective.
The Guidelines are silent and do not deal with issues
A doctor may charge an appropriate fee for the
pertaining to hardware, software, technology, data
Telemedicine consultation and also provide a receipt/
management and other IT related issues. However they
invoice for the same.
mandate that it is the doctors’ responsibility to be aware of
Most platforms for teleconsultation charge an upfront data protection and privacy laws. The pediatrician has to
fee to register the doctor services cover managing the maintain logs of all teleconsultations, records, prescriptions
appointment, storing patient data, sending an invoice and and has to maintain reasonable degree of confidentiality.
mailing the prescription. Some platforms deduct 10-20%
During a telemedicine consult, identification of the
from the fees charged by the doctor.
patient and the pediatrician is important. 8
A practical way is for the doctor to complete the
A detailed consent with mention regarding mode of
consultation via a video or audio call following which a
communication and type of consultation is necessary.
photo of the prescription on his/her letterhead may be sent
Besides, we have to keep the following points in mind:
to the patient. This ensures documentation and security of
patient data. Fee payment can be made through NEFT / 1. Legal aspect
Google pay which circumvents service fee to the platforms
2. Consent
and benefits doctor and patient alike.
3. Privacy and security of patient data and identity
IAP has also suggested a simple solution using some
of the most widely used and secure platforms in the world 4. Pharmacy rules
- WhatsApp Business for consultation or Paytm 5. Insurance coverage to the patient
(for Business) to manage payments. A doctor can start his
6. Indemnity coverage of the consultant
/ her telemedicine practice within 30 mins in 2 simple steps:
7. Issues of liability and negligence
1. Download and setup WhatsApp Business and Paytm
for Business Apps on the mobile. 8. Referral for emergency9
2. Activate special Paytm features by registering his/ her 9. Misuse and abuse of data
account on https://diapindia.org/telemedpaytm.php. 10. Rules pertaining to the place of residence of the patient
Thus, instead of subscribing to an expensive Conclusion
telemedicine software charging Rs. 15-20,000/- per annum,
with the ever present ‘Damocle’s sword’ of data misuse, During the COVID-19 pandemic, there has been a
IAP’s solution is very simple and employs time tested significant decrease in the number of patients visiting the
platforms. And this is completely free for IAP members. pediatric outpatient department. While in person
consultation is the preferred mode, telemedicine can be
Benefits for IAP members from Paytm used for health supervision visits and acute and chronic
care visits. It is useful for for essential newborn screening,
• All IAP doctors will get upgraded as ‘Unlimited
initial assessment of children with minor illness and follow
Merchants’ and get payment link enabled. These are
up visits after discharge from hospital, infection control
enterprise level features and not available to individual
and immunization advice.Well baby clinics can be
Paytm merchants.
encouraged to use telemedicine with the rider that general
• Special deal on physical POS/ EDC machine once the examination cannot be done during teleconsultation.9
lockdown is over – Paytm field team will be in touch Laboratory tests, hearing, vision and oral health screening
directly. An EDC (electronic data capture) works to should be completed in person when circumstances
make use of POS (point of sale) terminals for credit improve. Chronic care can easily be carried out through
card processing in addition to its submission to the e- telemedicine. It is important to remember that telemedicine
commerce providers of merchant accounts or other cannot replace physical examination. With the advent of
types of credit card processors. newer technologies, even some of the requirements for
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Indian Journal of Practical Pediatrics 2020;22(2) : 229

physical examination can be addressed. Telemedicine for COVID-19.N Engl J Med 2020. 382:1679-1681.
despite its limitations, will continue to grow and be adopted doi:10.1056/NEJMp2003539.
by more and more pediatricians and patients in future. 5. Dasgupta A, Deb S. Telemedicine: a new horizon in public
health in India. Indian J Community Med. 2008; 33(1):
References 3-8. doi:10.4103/0970-0218.39234.
6. Kopp S, Schuchman R, Stretcher V, Gueye M, Ledlow J,
1. Burke BL Jr, Hall RW. Telemedicine: Pediatric Philip T, et al. Telemedicine. Telemed J E-health. Spring
Applications. Pediatrics 2015;136(1):293-308. 2002; 8:1 35-48.
2. Eccleston C, Blyth FM, Dear BF, Fisher EA, Keefe FJ, 7. Singh, M. Das, R.R. Utility of telemedicine for children in
Lynch ME, et al. Managing patients with chronic pain India. Indian J Pediatr 2010; 77: 73-75.
during the COVID-19 outbreak: considerations for the 8. McSwain SD, Bernard J, Burke BL Jr, Cole SL,
rapid introduction of remotely supported (eHealth) pain Dharmar M, Hall-Barrow J et al. American telemedicine
management services. Pain. 2020;161(5):889-893. association operating procedures for pediatric telehealth.
Accessed on 3rd June 2020. Telemed J E Health 2017; 23(9):699-706.
3. Dwivedi S, Roy K. Comment: Telemedicine: An Era Yet 9. Ministry of Health and Family welfare.
to Flourish in India. Annals Of The National Academy Of Telemedicine Practice Guidelines, Enabling Registered
Medical Sciences (India). 2020; 56(01): 50. doi: 10.1055/ Medical Practitioners to Provide Health care through
s-0040-1710195. Telemedicine. Available from https//www.mohfw.gov.in/
4. Hollander JE, Carr BG. Virtually perfect? Telemedicine pdf/telemedicine.pdf. Accessed on 3rd June 2020.

CLIPPINGS

COVID-2019 infection among health care workers.

Data were collected from January 1 to February 9, 2020. Exposure, epidemiological and demographic
information was collected by a structured questionnaire. Clinical, laboratory and radiologic information
was collected from electronic medical records. A total of 335 medical staff were randomly sampled to
estimate the prevalence of subclinical infection among a high-risk, asymptomatic population. Samples from
surfaces in health care settings were also collected. Overall, 110 of 9684 HCWs in Tongji Hospital tested
positive for COVID-19, with an infection rate of 1.1%. Seventeen (15.5%) worked in fever clinics or wards,
indicating an infection rate of 0.5% (17 of 3110) among first-line HCWs. A total of 93 of 6574 non–first-line
HCWs (1.4%) were infected. Non–first-line nurses younger than 45 years were more likely to be infected
compared with first-line physicians aged 45 years or older (incident rate ratio, 16.1; 95% CI, 7.1-36.3;
P < .001). The prevalence of subclinical infection was 0.74% (1 of 135) among asymptomatic first-line
HCWs and 1.0% (2 of 200) among non–first-line HCWs. No environmental surfaces tested positive.
Overall, 93 of 110 HCWs (84.5%) with COVID-19 had nonsevere disease, while 1 (0.9%) died. The 5 most
common symptoms were fever (67 [60.9%]), myalgia or fatigue (66 [60.0%]), cough (62 [56.4%]),
sore throat (55 [50.0%]), and muscle ache (50 [45.5%]). Contact with indexed patients (65 [59.1%]) and
colleagues with infection (12 [10.9%]) as well as community-acquired infection (14 [12.7%]) were the main
routes of exposure for HCWs.

Conclusions: That non–first-line HCWs had a higher infection rate than first line HCWs differed from
observation of previous viral disease epidemics. Rapid identification of staff with potential infection and
routine screening among asymptomatic staff could help protect HCWs.

Lai X, Wang M, Qin C, Tan L, Ran L, Chen D, et al. COVID-2019 infection among HCWs and implications
for prevention measures in a tertiary hospital in Wuhan. JAMA Network Open 2020; 3(5):e209666.
May 21st 2020 P. 1-12 doi:10.1001/jamanetworkopen.2020.9666.

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Indian Journal of Practical Pediatrics 2020;22(2) : 230

RADIOLOGY

IMAGING IN URINARY TRACT INFECTION Ultrasound is best done 2 weeks after an attack of UTI as
toxin from E.coli, which is the commonest organism, can
*Vijayalakshmi G cause dilatation of the collecting system.
**Balaji S
***Raveendran J However, ultrasound is urgently required in the
***Abirami Mahadevan presence of continued spiking of temperature, loin mass
or tenderness or rising creatinine to assess the status of the
Urinary tract infection (UTI) is a clinical diagnosis kidneys and development of complications. In acute
and confirmation is done with urine analysis and culture. pyelonephritis, the kidneys can appear normal or maybe
The role of radiology, as we have seen in earlier issues, is mildly enlarged with or without a mild increase in
to rule out obstructive and congenital anomalies that parenchymal echogenicity and loss of corticomedullary
predispose to urinary tract infection. This is why all children differentiation. These findings are due to tissue edema.
less than 2 years with UTI are advised ultrasound abdomen Movement with respiration may be reduced.
for study of the urinary tract, which is a very simple Sometimes focal inflammation and vasospasm can cause
investigation. Another important radiological investigation a hypoechoic lesion that can be mistaken for a mass.
is the micturating cystourethrogram for ruling out vesico- But, unlike a mass there is reduced vascularity which is
ureteric reflux. Though it is the gold standard for diagnosis more easily appreciated with power Doppler. Abscess
and grading of vesico ureteric reflux (VUR), it carries the formation can also be a complication of pyelonephritis
risk of inducing UTI and also means much discomfort for (Fig.1) shows multiple small abscesses in an enlarged
the patient. Therefore it is reserved for recurrent UTI, kidney. (Fig.2) shows an abscess in the mid segment of the
atypical UTI, family history of VUR and when there is kidney which has perforated the capsule to collect in the
ureteric dilation in the ultrasound in the absence of perinephric space that has to be drained. A cyst in the upper
obstructive abnormalities. Sometimes the indications may pole (Fig.3) is a common finding. If infected, they develop
be expanded to male children and all children with UTI
who are less than 5 years.
Dimercapto succinic acid (DMSA) is another
investigation, role of which in UTI is not clear. In acute
pyelonephritis inflammed areas are seen as cold areas or
photopenic areas. False negative scans may occur if
infection is confined to the medulla and has not yet reached
the cortex or due to immature renal tubular function in
infants less than 3 months. The cold areas may resolve,
usually in 3 months, or persist if irreversible scarring has
occurred. Consequently the timing of the scan is 3 to
6 months after infection. The MCU is done 4 weeks after
UTI has subsided as transient VUR may sometimes be seen
during infection and because it is an invasive test.
* Professor
** Associate Professor
*** Assistant Professor,
Department of Pediatric Radiology,
Institute of Child Health and Hospital for Children,
Madras Medical College, Chennai. Fig.1. Multiple small pyemic abscesses in the
email : drviji.rad@gmail.com kidney
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Fig.2. Abscess (A) in the kidney with

perinephric collection (arrows)
Fig.3. Infected cyst in the upper pole of the
kidney

Fig.4. CT Abdomen-Air in the kidney (arrow)

- emphysematous pyelonephritis

a thick wall, plenty of septations and turbid content.

Fig.5.Xanthogranulomatous pyelonephritis.
Turbidity of content in the bladder or in a dilated collecting
Note calculus(c) and collections of exudate(i)
system could be due to infective debris, but they are also
seen in nephritis and nephrotic syndrome due to cell debris
and with the use of certain drugs that induce crystalluria.
Thickening of the urothelium may be seen in
pyelonephritis. In CT, abscesses are seen as low attenuation
foci that show an enhancing rim on contrast.
There are some special types of pyelonephritis.
Emphysematous pyelonephritis is a necrotizing infection
of the kidneys characterised by gas formation in the kidneys
usually due to E.coli. Klebsiella and Proteus mirabilis.
It is seen more often in adults with diabetes mellitus.
Ultrasound shows an enlarged kidney with bright echoes
that are different from calculi in that the after shadows are
not dark and sharp as in calculi but irregular with less bright
echoes due to reverberation. CT is the modality of choice
as air is seen more clearly as black streaks or collections Fig.6. CT abdomen - Aspergillus cast in renal
(Fig.4) or as air-fluid levels in abscesses. pelvis (arrow)
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Xanthogranulomatous pyelonephritis is actually an due to the propensity for fibrosis causing infundibular
abnormal immune response to subacute bacterial infection. stricture. Calcification is seen very often in tuberculosis.
This is also more often seen in diabetics. Though rare it
can be seen in children. Classically the kidney is enlarged, Fig.6 is that of a child whose left renal pelvis shows
there is a large pelvic calculus in a contracted pelvis and an aspergillus cast seen as a filling defect. This can occur
there is no excretion on contrast administration. What looks in the immunocompetent also. They usually follow
like dilated calyces are actually inflammatory exudates instrumentation and need to be removed surgically. Invasive
(Fig.5). Rarely it can be focal, or not associated with aspergillosis is seen in grossly immunosuppressed patients.
calculus or seen with renal atrophy. Though it is generally agreed upon that radiological
Tuberculous pyelonephritis occurs with hematogenous evaluation in urinary infection does not always have an
seedling. Initially there is papillary necrosis which impact on treatment, targeted imaging in specific clinical
manifests as an enlarged calyx. The calyx can further dilate situations is necessary.

CLIPPINGS

Classification of the cutaneous manifestations of COVID 19.

Dermatologists carried out a nationwide case collection survey of images and clinical data of 375 patients during
peak of the COVID-19 pandemic in Spain. Patients with most severe disease were excluded. Using a consensus they
described clinical patterns and the association of these patterns with patient demographics, the timing in relation to
symptoms of the disease, the severity and the prognosis. The strength of the study is that the description of clinical
patterns has been done by experts based only on morphology. The 5 clinical patterns included pseudo-chilblain
(19%), other vesicular eruptions (9%), urticarial lesions (19%), other maculopapules (47%) and livedo or necrosis
(6%). There were also reports of increased numbers of herpes zoster cases in patients with COVID-19. While Pseudo-
chilblain lesions tended to affect younger patients with less severe disease, vesicular lesions appeared more in middle-
aged patients with intermediate severity of disease. Urticarial, maculopapular and livedoid/necrotic lesions were all
associated with more severe disease. A mortality rate of 10% was noted in the livedoid/necrotic group. They suggest
that further research could be improved by having more tests to confirm COVID-19 and to exclude other infections,
and utility of this classification should be confirmed in clinical use.
Casas CG, Català AG, Carretero, Hernández GC, Rodríguez Jiménez P, Fernández Nieto D, et al. Classification of
the cutaneous manifestations of COVID 19. Br J Dermatol 2020 Apr 29 doi: 10.1111/bjd.19163 [Epub ahead of
print].

Gastrointestinal features in children with COVID-19: an observation of varied presentation in eight children.
Eight children were referred for pediatric surgical review over an 8-day period (April 25-May 2, 2020).
They presented with fever, abdominal pain, diarrhea and vomiting presenting at a single centre in the UK.
The working diagnosis was of systemic sepsis based on raised blood inflammatory markers thought to be secondary
to suspected appendicitis. All patients apart from one presented with markedly elevated CRP. USG/CT was done and
the findings were lymphadenopathy and presence of inflammatory fat throughout the mesentery, with thickening of
the terminal ileum and non-inflamed appendix. One child had a severe inflammatory response and myocarditis,
Three other developed systemic inflammatory response and haemodynamic instability requiring inotropes.Two among
eight were SARS-CoV-2 PCR was negative, but strongly suspected because of the similarity of their clinical presentation
and imaging. They were treated with immunoglobulin and steroid treatment for atypical Kawasaki disease.
No patients have died. Given the convincing nature of clinical findings for appendicitis in children with
COVID-19, we stress the importance of abdominal imaging and a swab for SARS-CoV-2 PCR in all children with
clinically suspected appendicitis, before surgical intervention. It is important to stress the need to visualise the appendix
through ultrasound, CT or both.
Tullie L, Ford K, Bisharat M, Watson T, Thakkar H, Mullassery D. Gastrointestinal features in children with
COVID-19: an observation of varied presentation in eight children. Lancet Child Adolesc Health 2020 Published
Online May 19, 2020 https://doi.org/10.1016/ S2352-4642(20)30165-6.
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Indian Journal of Practical Pediatrics 2020;22(2) : 233

CASE REPORT

CHALLENGES ENCOUNTERED IN severe acute respiratory infection (SARI) suspicious of

MANAGING NON COVID-19 ILLNESS COVID-19. On arrival, child was febrile, severely
DURING A PANDEMIC distressed and hypoxic with poor air entry on left side. He
required emergency intubation using full personnal
*Supraja Chandrasekar protective equipment (PPE). Chest radiograph (CxR)
**Sindhu Malvel showed mediastinal shift to left side with reduced volume
*Gurudutt AV of left hemithorax with collapse/consolidation of entire left
lung (Fig.1). Ventilator settings were PEEP-6, PIP-20, rate-
Abstract: The SARS-CoV-2 pandemic has impacted health
30 with 100% FiO2. High total counts 28,820 cells/ mm3
care delivery in an unprecedent manner. The uprising
and CRP 5.6 mg/dL were noted. Piperacillin tazobactam
COVID-19 trend in India, combined with the information
and vancomycin were started. Computerized tomography
explosion and resource constraints have contributed to
(CT) chest showed collapse of left lung with obstruction
uncertainty in managing otherwise straight forward
due to suspected mucus plugging of left main bronchus
emergencies. Here, we report challenges faced whilst
(LMB) and patchy consolidation on the right lower zone
managing a child with a common illness in the COVID-19
(Fig.2). Parents denied any history of choking suggestive
period. Modification of current practices and developing
of foreign body (FB) aspiration. RT PCR for COVID-19
universal precautions against COVID-19 is needed to
was done and it took 36 hours to get the result which was
overcome challenges in managing non COVID-19 patients
negative. Positioning, suctioning, mucolytics and
during this pandemic.
ventilatory strategies failed to show improvement and
Keywords: SARS-CoV-2, Foreign body aspiration, hence rigid bronchoscopy was planned.
Respiratory distress, Bronchoscopy.
Initially the surgeon and anesthetist were reluctant to
The SARS-CoV-2 pandemic has impacted the world intervene, as he was COVID-19 suspect and high risk of
especially clinicians in unprecedented ways.1 India sees a aerosol generation during the procedure. However, as child
rising trend, with over 130,000 positive cases as on was severely hypoxic, emergency flexible bronchoscopy
May 2020.2 Compelling data on high infectivity especially was performed in the pediatric intensive care unit,
to health care workers (HCW), asymptomatic carriage and confirming mucoid obstruction in left main bronchus
limitations of testing, coupled with constraints of resource which could not be extracted. Emergency rigid
such as personal protective equipment (PPE) have led to bronchoscopy was then performed in the operating theatre.
fear amongst Indian HCWs affecting health care delivery.1
Here, we report challenges faced whilst managing a child
with a common illness in the COVID era.

Case report
A 2 year-old boy from rural Karnataka presented with
two-week history of cough, preceded by transient fever.
His cough worsened 2 days prior to presentation with
breathlessness and recurring fever. He was referred as

* Consultant Pediatric Intensivist

** Junior Consultant Pediatric Intensivist,
People Tree Hospitals,
Bengaluru.
email:drschandrasekar@yahoo.com Fig.1. Left lung collapse on chest radiograph
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Indian Journal of Practical Pediatrics 2020;22(2) : 234

Fig.2. CT showing obstruction at LMB with Fig.3. Extracted foreign body areca nut
lung collapse

Three pieces of areca nut were removed from the left main of FB.5 Flexible bronchoscopy is diagnostic and sometimes
stem bronchus and saturations dramatically improved therapeutic for distal FBs.3 Rigid bronchoscopy remains
(Fig.3). Child was extubated the next day and was the gold standard which shouldn’t be delayed when FB is
discharged in 3 days. suspected.3,5 However, in clinical COVID-19 suspects,
Discussion knowing limitations of RT PCR testing, bronchoscopies
may be avoided due to high aerosolization and viral
Foreign body (FB) aspiration is a life-threatening transmission, especially in OT with risk of exposure to
emergency that peaks in toddlers with male multiple personnel. 8 Recent pediatric guidelines on
preponderance.3 Vegetable FBs notably peanut, lodged in modified/ newer approaches to these procedures with
right main bronchus is typical.3,4,5 Cough, respiratory simulation training allow for safer practices.1,9,10
distress, wheezing and hypoxia are common presentations.
Unilateral decreased air entry, wheeze, stridor and distress Conclusion
are seen.3,4,6 Fever is associated with late presentation and Children with non COVID health issues suffer more
leading history is absent in 40% cases both of which were than the COVID-19 positive patients during this pandemic.
observed in our case.4 During this pandemic era as shown Even the number of children who suffer from non COVID
in the Chinese series, cough and fever were commonest problems are more than that with COVID-19. Diagnosis
symptoms of COVID-19.7 Coupled with hypoxia and and management of even common conditions like FB
respiratory distress, they qualify as SARI and a aspiration may get delayed or totally missed because of
COVID-19 suspect according to Indian guidelines. Hence fear or mislabeling as COVID-19. This is an avoidable
a clinical presentation which in other times would have impact of current pandemic. One should have an open mind
straightaway led us to suspect FB, masqueraded as to consider non COVID causes during the evaluation of
COVID-19. However, unilateral lung collapse with COVID-19 suspects. Following universal precautions,
obstruction of LMB pointed to a different diagnosis. modified approach and simulation preparedness can
Typically in FB aspiration, CXR may show obstructive overcome the risks faced by HCW during anesthesia and
emphysema or unilateral collapse, mediastinal-shift, an high aerosol generating procedures. Lesson learnt is that
opaque FB or even normal study.34,5,6 CT has better one should consider non COVID treatable illnesses,
sensitivity and specificity than the CXR in the evaluation amongst COVID-19 suspects and evaluate and treat them
of collapse and may even delineate the exact location skillfully.

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Indian Journal of Practical Pediatrics 2020;22(2) : 235

References 6. Aslan N, Yýldýzdaþ D, Özden Ö, Yöntem A, Horoz ÖÖ,

Kýlýç S. Evaluation of foreign body aspiration cases in
1. Matava GT, Kovatsis PG, Summers JL, Castro P, our pediatric intensive care unit: Single-centre experience.
Denning S, Yu J, et al. Pediatric Airway Management in Turk Pediatri Ars 2019; 54(1): 44–48.
COVID-19 Patients: Consensus Guidelines From the
7. Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. SARS-
Society for Pediatric Anesthesia’s Pediatric Difficult
CoV-2 infection in children. N Engl J Med. 2020
Intubation Collaborative and the Canadian Pediatric
23;382(17):1663-1665. doi: 10.1056/NEJM2005073.
Anesthesia Society. Anesthesia and Analgesia. 2020
Epub 2020 Mar 18.
Jul;131(1):61-73. doi: 10.1213/ane.0000000000004872.
2. Ministry of Health and Family Welfare. Available from: 8. Liguoro I, Pilotto C, Bonanni M, Ferrari ME, Pusiol A,
https://www.mohfw.gov.in. Accessed on 25th May, 2020. Nocerino A, et al. SARS-COV-2 infection in children and
newborns: a systematic review [published online ahead of
3. Salih AM, Alfaki M, Alam-Elhuda DM. Airway foreign
print, 2020 May 18]. Eur J Pediatr. 2020;1-18. doi:10.1007/
bodies: A critical review for a common pediatric
s00431-020-03684-7
emergency. World J Emerg Med 2016;7(1):5-12.
doi:10.5847/wjem.j.1920-8642.2016.01.001. 9. Pollaers K, Herbert H, Vijayasekaran S.
4. Parameswaran N, Das S, Biswal N. Respiratory Morbidity Pediatric Microlaryngoscopy and Bronchoscopy in the
Following Foreign Body Aspiration Among South Indian COVID-19 Era. JAMA Otolaryngol Head Neck Surg.
Children: A Descriptive Study. Cureus. 2018;10(11):e3629. Published online April 28, 2020. doi:10.1001/
Published 2018 Nov 23. doi:10.7759/cureus.3629. jamaoto.2020.1191.
5. Dorterler ME, Kocaman OH, Gunendi T, Boleken ME. 10. Wang TT, Moon HS, Le A, Panchal N. Proceedings of the
A single-center experience of pediatric foreign-body OMS COVID-19 Response Conference [published online
aspiration: A retrospective 4-year case series. Lung India. ahead of print, 2020 May 11]. J Oral Maxillofac Surg 2020;
2019;36(3):202-206. doi:10.4103/lungindia.lungindia_ S0278-2391(20)30456-0. doi:10.1016/j.joms. 2020.05.
69_18. 003.

CLIPPINGS

Convalescent plasma for patients suffering from COVID-19 Study done in Wuhan, China.
A multicenter, open-labelled randomized controlled trial on patients with severe or life-threatening COVID-19
was performed in Wuhan, China, enrolling 103 adult participants ( Study aimed to enroll 200 but terminated
early for lack of patients). The objective was to evaluate the efficacy and adverse effects of convalescent plasma
therapy in severe (respiratory distress and/or hypoxemia) or life-threatening (shock, organ failure, or requiring
mechanical ventilation) disease.
Convalescent plasma was obtained from persons who had recovered from COVID-19 and were more than
2 weeks out from hospital discharge. Only plasma with an IgG titer against the S protein-receptor binding
domain of at least 1:640 was used, at a dose of 4 to 13 mL/kg (median infusion, 200 mL). The primary endpoint
was time to clinical improvement within 28 days, defined as discharge or a reduction of 2 points on a 6-point
disease severity scale. 52 patients (23 with severe and 29 with life-threatening disease) were enrolled. Clinical
improvement occurred in 27 convalescent-plasma recipients (51.9%) and 22 control patients (43.1%), a
nonsignificant difference. Among those with severe disease, the primary outcome occurred in 91.3% versus
68.2%, suggesting a possible benefit, but the test for interaction by disease severity was not significant.
The early termination could have underpowered the study, the authors note.
This well-conducted randomized clinical trial of convalescent plasma in patients with COVID-19 suggests that
this treatment is not of benefit in all patients but may have a role in some patients with severe disease. Further
studies are needed to study the utility of convalescent sera .
Li L et al. Effect of convalescent plasma therapy on time to clinical improvement in patients with severe and
life-threatening COVID-19: A randomized clinical trial. JAMA 2020 Jun 3; [e-pub]. (https://doi.org/10.1001/
jama.2020.10044).

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Indian Journal of Practical Pediatrics 2020;22(2) : 236

CASE REPORT

UNUSUAL PRESENTATION OF COVID-19 introduction of new weaning food in the past week.
AS INTUSSUSCEPTION There was no irritability or crying spells suggestive of
abdominal pain. He had no respiratory symptoms, rashes
*Lalitha Rajalakshmi or ear discharge. There was no history of contact with
**Sharada Satish COVID-19 patients or any history of recent travel or new
***Nandhini G visitor in the home. It was decided to send a nasopharyngeal
****Ezhilarasi S swab for RT-PCR for SARS-CoV-2, on third day of illness
considering the fact that gastrointestinal manifestations are
Abstract: COVID-19, caused by novel coronavirus SARS-
one of the presentations in children with COVID-19, as
CoV-2, presents with varied clinical manifestations in
seen in studies published from Wuhan Province, China.
pediatric age group. Gastrointestinal (GI) symptoms with/
without respiratory manifestations are increasingly On examination, he was lethargic, febrile (99.4ºF),
reported in children. This infant presented with features of with HR of 120/min, RR of 45/min, and SpO2-98%.
intussusception and fever. Further evaluation showed RT Signs of some dehydration such as sunken eyes and
PCR positivity for COVID-19 in the nasopharyngeal swab. listlessness were present. Examination of the abdomen
Child did not develop any other respiratory manifestations revealed an ill-defined mass palpable in the abdomen, with
or features of hyperinflammatory syndrome. It is extremely normal bowel sounds and no distension. The stools were
difficult to distinguish if this a manifestation of of red currant jelly type. Cardiovascular, respiratory and
COVID-19 or an associated illness. nervous system examination showed no significant
abnormality.
Keywords: Intussusception, COVID–19, SARS-CoV-2,
Children. Intussusception was suspected and the child was
started on intravenous fluid and other supportive
Intussusception is one of the commonest surgical
management. Emergency ultrasound was done which
emergencies encountered in infants between 6-12 months
confirmed the ileocolic intussusception in the subxiphoid
of age, usually following gastrointestinal infections or
region (Fig.1). Investigations revealed a Hb of 10.5 g/dL,
introduction of complementary feeds. Here, we report an
and hematocrit of 32.7%, total count was 7590 cells/mm3
unusual presentation of COVID-19 as intussusception.
with polymorphic predominance of 72% and lymphocytes
Case Report of 23%, platelet count was 3.04 lakhs/mm.3 Renal function,
electrolytes and coagulation profile were within normal
An 8 months old male infant, presented with low-grade limits. Pediatric surgeon’s opinion was obtained and
fever for 2 days, 6-7 episodes of non-bilious, non-projectile emergency pneumatic reduction was planned.
vomiting and 2 episodes of blood-stained stools for 1 day.
He was a well thriving and developmentally normal child. Child underwent pneumatic reduction (Fig.2) of
He has been on breast feeds and complementary feeding ileocolic intussusception at the level of transverse colon
was started at 6 months of age. There was a history of and the same was reduced in a single attempt.
Child tolerated the procedure well. Dehydration was
* DNB Resident corrected, follow up screening ultrasound showed no
recurrence, fever and vomiting settled, slowly feeds were
** Consultant Pediatric Emergency Physician
initiated. However, surprisingly, the nasopharyngeal RT -
*** Consultant Pediatric Surgeon
PCR sample sent for SARS - CoV- 2 came as positive,
**** Consultant Pediatrician, suggesting that intussusception could be a manifestation
Department of Pediatrics and Pediatric Surgery,
of COVID -19 in young infants. There were no recurrence
Mehta Multispecialty Hospitals Pvt. Ltd,
of symptoms, fever or respiratory manifestations, hence
Chennai
no other treatment was initiated. Parents were tested for
email: sharadasathishkumar@gmail.com
COVID-19 by nasopharyngeal swab RT-PCR on day 5 of
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Indian Journal of Practical Pediatrics 2020;22(2) : 237

Fig.1. Ultrasound showing intussusception Fig.2. Pneumatic reduction under C-Arm

exposure and were negative. Child was stable with no enzyme 2 (ACE2) to enter human cell. ACE2 is highly
deterioration during 5 days of hospital stay and was expressed in type II alveolar cells in the lungs and in
discharged and advised home isolation. Further procedures gastrointestinal tract, especially in the small and large
of isolation, notification, quarantining and screening of intestines. Staining of viral nucleocapsid protein has been
contacts were initiated as per government protocol. Follow visualized in cytoplasm of gastric, duodenal, and rectal
up telephonic consultation was done, child remained well epithelium. The presence of SARS-CoV-2 RNA in anal/
and repeat RT-PCR was done and found to be negative. rectal swabs and stool specimens even after the clearance
of the virus in the upper respiratory tract and expression of
Discussion the viral receptor ACE2 in gastrointestinal epithelial cells
Evidence regarding pediatric COVID-19 is still substantiates the GI involvement in COVID-19.8 In fact,
evolving. During the ongoing pandemic, COVID-19 must the first ever severe case reported in pediatrics presented
be considered in patients with increased inflammatory with GI manifestations progressing to acute respiratory
variables and abdominal symptoms.1 The most common distress syndrome.9
GI manifestations include diarrhea, vomiting and acute It has been observed that there is an increased GI wall
abdominal pain. A positive contact history is elicitable in permeability to foreign pathogens once infected by the
majority of the cases.2 SARS-CoV-2 virus. The radiologic manifestation of these
Both respiratory (cough, rhinorrhea, sore throat, findings are distended fluid filled small and large bowel
tachypnea) and GI (diarrhea, vomiting) manifestations loops with mural post-contrast enhancement with
along with fever have been described in children with surrounding stranding on CT and ileus pattern on
COVID-19'.3,4,5 However, Cai, et al., in their report on 10 abdominal radiographs.10 It is well known that GI infection
pediatric patients, observed respiratory manifestations leading to swollen Peyer’s patches in terminal ileum is the
(cough, sore throat, stuffy nose, sneezing, rhinorrhea), cause for mucosal prolapse of ileum into colon resulting
while none had diarrhea or dyspnea.6 In a meta- analysis in intussusception. Thus, the demonstrated GI inflammation
of 266 pediatric and 6064 adult COVID-19 patients, and infection by SARS- CoV-2 makes us consider
GI symptoms including diarrhea, nausea or vomiting were intussusception as a possible manifestation of COVID-19.
observed similarly in both groups. It was observed that Literature on COVID-19 presenting as intussusception
10% of pediatric patients (95% CI 4-19; range 3-23; are scarce. Lu, et al have reported 10 months old infant
I²=97%) presented with gastrointestinal symptoms alone with intussusception, who progressed to multiorgan
without respiratory features.7 dysfunction and succumbed in 4 weeks. 11 However,
Genome sequences showed that SARS-CoV-2 mortality in COVID-19 children is relatively lower than
expresses the spike (S) glycoproteins that could bind with adults. Most routine blood examinations were normal, and
high affinity to the entry receptor angiotensin converting C reactive protein levels were normal or transiently
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Indian Journal of Practical Pediatrics 2020;22(2) : 238

increased, except in cytokine storm syndrome.9,12 These 3. Xu Y, Li X, Zhu B, Liang H, Fang C, Gong Y, et al.
lab findings were consistent with the present case. Characteristics of pediatric SARS-CoV-2 infection and
potential evidence for persistent fecal viral shedding.
Our index child presented here did not progress to Nat Med. 2020;6(4):502-505.
respiratory involvement or cytokine storm syndrome or 4. Xia W, Shao J, Guo Y, Peng X, Li Z, Hu D. Clinical and
multiorgan dysfunction and hence we did not proceed to CT features in pediatric patients with COVID-19 infection:
do transaminases, ferritin, D-dimer assay and other Different points from adults. Pediatr Pulmonol.
inflammatory markers. Rectal swab was not done as well, 2020;55(5):1169-1174.
as the child recovered clinically. None of the other family 5. Hasan A, Mehmood N, Fergie J. Coronavirus Disease
members/contacts developed any symptoms and their (COVID-19) and Pediatric Patients: A Review of
screening for SARS CoV-2 was negative, at the time of Epidemiology, Symptomatology, Laboratory and Imaging
hospitalization of the child and up to two weeks after Results to Guide the Development of a Management
discharge. There are not many standardized studies Algorithm. Cureus. 2020 ;12(3):e7485. doi: https://doi.org/
regarding data on the sensitivity and specificity of RT-PCR 10.7759/cureus.7485.
for COVID-19. However, in a study providing invitro data 6. Cai J, Xu J, Lin D, Yang Z, Xu L, Qu Z, et al. A Case
with minimal clinical information have shown high Series of children with 2019 novel coronavirus infection:
specificity and moderate sensitivity (63-78%)13. As per clinical and epidemiological features [published online
American Society for Microbiology COVID-19 ahead of print, 2020 Feb 28]. Clin Infect Dis 2020;ciaa198.
doi:10.1093/cid/ciaa198.
International Summit report, a negative test does not
exclude the possibility of infection. A positive test is most 7. Mao R, Qiu Y, He JS, Tan JY, Li XH, Liang J, et al.
likely correct, although stray viral RNA that cross Manifestations and prognosis of gastrointestinal and liver
contaminates from an infected laboratory worker (while involvement in patients with COVID-19: a systematic
review and meta-analysis. Lancet Gastroenterol Hepatol
the specimen is being collected or tested) could result in a
2020 DOI: https://doi.org/10.1016/S2468-1253(20)
falsely positive result.14 30126-6.
In conclusion, this case report shows the variability 8. Wong SH, Lui RNS, Sung JJY. Covid-19 and the digestive
in the clinical presentation of COVID-19. Gastrointestinal system. J Gastroenterol Hepatol 2020;35(5):744-748.
manifestations should raise the suspicion of SARS-CoV-2 9. She J, Liu L, Liu W. COVID-19 epidemic: Disease
and authors would like to emphasize the need for increased characteristics in children. J Med Virol [Internet].
testing to identify the causal association in children. In this 2020;(March):1-8. Available from: http://dx.doi.org/
index child, intussusception may be a GI manifestation of 10.1002/jmv.25807.
COVID -19, due mucosal inflammatory changes or may 10. Behzad S, Aghaghazvini L, Radmard AR,
be an unrelated problem. Though clinical syndrome is still Gholamrezanezhad A. Extrapulmonary manifestations of
in an evolving stage, it is worthwhile to evaluate all children COVID-19: Radiologic and clinical overview. Clin
with acute abdomen for COVID-19 and it is equally Imaging 2020;66:35-41.
important that surgery and radiology team should take 11. Lu X, Zhang L, Du H, Zang J, Zang J, Li YY, et al.
proper preventive measures including hand hygiene and SARS-CoV-2 infection in children. N. Engl. J. Med.
wearing PPE. 2020.
12. Ludvigsson JF. Systematic review of COVID-19 in
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 IAP Team - 2020 Indian Academy
of Pediatrics
President Jharkhand
Dr.Bakul Jayant Parekh Dr.Sudhir Mishra
President Elect Karnataka
Dr.Piyush Gupta Dr.Geeta Patil
Imm. Past President Dr.C.N.Raghunath
Dr.Digant D Shastri Dr.Rajakumar N Marol
Vice President-Central Zone Dr.N.K.Subramanya
Dr.G.Sudhakar Kerala
Vice President-East Zone Dr.Abraham K Paul
Dr.Nigam Prakash Narain Dr.Jose Ouseph
Vice President-West Zone Dr.P.A.Mohammed Kunju
Dr.Chandrashekhar S Dabhadkar Dr.M.K.Santosh
Vice President-North Zone Madhya Pradesh
Dr.A.S.Vasudev Dr.Arvind K Upadhyay
Vice President-South Zone Dr.V.P.Goswami
Dr.T.M.Ananda Kesavan Maharashtra
Secretary General Dr.Anil Shriram Raut
Dr.G.V.Basavaraj Dr.Jayant G Joshi
Treasurer Dr.Mahesh A Mohite
Dr.Purna A Kurkure Dr.Paramanad G Andankar
Editor-in-Chief, IP Dr.Prashant B Jadhav
Dr.Devendra Mishra Manipur
Editor-in-Chief, IJPP Dr.K.H.Ratankumar
Dr.S.Thangavelu Odisha
Joint Secretary- Liaison
Dr.Asutosh Mahapatra
Dr.Harish Kumar Pemde
Dr.Bishwajit Mishra
Joint Secretary- Admin
Punjab
Dr.Samir Hasan Dalwai
Dr.Gurdeep Singh
Members of the Executive Board
Dr.Harpreet Singh
Andhra Pradesh
Rajasthan
Dr.K.Venkata Ramana Murty
Dr.Jai Singh
Dr.P.S.Pawan Kalyan
Assam Dr.Raj Kumar Gupta
Dr.Rupam Das Tamilnadu
Bihar Dr.K.Muthukumar
Dr.Anil Kumar Dr.S.Narmada
Dr.Anil Kumar Jaiswal Dr.A.Somasundaram
Chandigarh Dr.P.Velusamy
Dr.Arun Bansal Telangana
Chhattisgarh Dr.Daruru Ranganath
Dr.Satyen D Gyani Dr.Neeli Ramchander
Delhi Dr.S.Srikrishna
Dr.Alok Bhandari Uttar Pradesh
Dr.Devender Gaba Dr.Ajay Srivastava
Dr.Gita Prasad Kaushal Dr.Sanjay Niranjan
Goa Dr.Vivek Saxena
Dr.Madhav Wagle Uttarakhand
Gujarat Dr.Utkarsh Sharma
Dr.Chetan B Shah West Bengal
Dr.Dhananjay R Shah Dr.Atanu Bhadra
Dr.Samir R Shah Dr.Pallab Chattopadhyay
Haryana Dr.Swapan Kumar Ray
Dr.Anjani Kumar Agarwal Services, IAP
Dr.Neelam Mohan AIR CMDE Daljit S Sangwan
Jammu & Kashmir Chief Organising Secretary
Dr.Sunil Dutt Sharma Dr.Ruchira Gupta