New COVID-19 guidelines: Know about home isolation, managing fever, and use of remdesivir

COVID-19 Guidelines: As the entire nation is struggling with a shortage of oxygen and other medical supplies amidst the second wave of the COVID-19 pandemic, the Health Ministry came out with two key documents on Thursday. One of the documents lists revised guidelines for home isolation of COVID-19 cases that are mild and asymptomatic, including drugs and treatment that can be prescribed by doctors to the patients. The second document lists the protocol for the management of novel coronavirus in the paediatric age group. Know about home isolation of patients, managing fever, and use of remdesivir in COVID-19 cases:

Recommendations on home isolation treatment

• For treatment in home isolation, general and specific recommendations have been made by the government. As per general guidelines, covid patients must be in communication with a treating physician and report promptly if there is any deterioration in their condition. After consulting the treating physician, the patient should continue the medication for other co-morbid illnesses.
• While specific guidelines suggest that covid patients follow symptomatic management for fever, cough, running nose as warranted. Besides covid patients may also take steam inhalation twice a day or perform warm water gargles.

What to do if the fever is not controlled?

• If the fever is not controlled with paracetamol tablets’ maximum dose (650 mg four times a day), the covid patient should consult the treating doctor who may advise other drugs such as non-steroidal anti-inflammatory drug like Naproxen (250 mg two times a day). As per the guidelines, the doctor may further consider ivermectin tablets for three to five days (200 mcg/kg once a day, taken on an empty stomach).
• In case the fever persists for more than five days of disease onset, inhalational budesonide (given through inhalers with spacer at 800 mcg dose, two times daily for five to seven days) can be given if symptoms like fever, cough are persistent for more than five days of disease onset.
• If the fever is persistant for more than seven days, with worsening cough, the patient should consult the doctor for treatment with low-dose oral steroids.

Should the covid patient take remdesivir?

• A medical professional must decide on administering remdesivir or other investigational therapy and it should only be administered in a hospital setting. As per the guideline, a person should not attempt to procure or administer remdesivir at home.
• The guideline strongly recommends that in case of falling oxygen saturation or breath shortness, the covid patient should require admission in hospital and seek prompt consultation of their treating physician or surveillance team.

What is the protocol for management of COVID-19 in children?

• The protocol lists separate guidelines for asymptomatic children, and the ones with mild, moderate and severe illness.
• As per the protocol, asymptomatic children don’t need any treatment, except monitoring for development of symptoms of covid as well as subsequent treatment according to assessed severity.
• Children having mild disease may come up with symptoms like sore throat, cough, runny nose with no breathing difficulty, and a few of them may have gastrointestinal symptoms. As per the guideline, such children do not require any investigation and can be managed under home isolation with symptomatic treatment.

What type of symptomatic treatment is recommended?

• For fever, the doctor should prescribe paracetamol (10 to 15 mg/kg/dose), which may be repeated every four to six hours. For cough, the doctor may recommend throat soothing agents like warm saline gargles.
• The doctor may recommend oral fluids to them to maintain hydration and a nutritious diet. For treating mild illness in children, antibiotics are not indicated.

How is moderate COVID-19 categorized in children?

As per the protocol, a child positive with Covid-19 will be categorised as having the moderate disease (oxygen saturations more than 90%) if he/she has the following rapid respiration benchmarks:

• Child below than 2 months: respiratory rate > 60 per min
• Child between 2-12 months: respiratory rate > 50 per min
• Child between 1-5 years: respiratory rate > 40 per min
• Child over 5 years: respiratory rate > 30 per min

The protocol states that children having moderate Covid may be suffering from pneumonia which may not be apparent clinically. It further mentions that no lab tests are needed routinely, unless indicated by associated co-morbid conditions.

What is the recommended treatment?

• Children with moderate novel coronavirus should be admitted to a dedicated Covid health centre or in a facility of secondary-level healthcare, and should be monitored for clinical progress.
• The protocol recommends that fluid, as well as electrolyte balance, should be maintained. It recommends oral feed (breast feeds in infants); in case the oral intake is poor then intravenous fluid therapy should be initiated.

What should be administered to children with moderate COVID-19?

• For fever, paracetamol 10 to 15 mg/kg/dose, which may be repeated every four to six hours (temperature > 38°C).
• If there is evidence/strong suspicion of bacterial infection then Amoxycillin to be administered.
• Oxygen supplementation is required for oxygen saturation below 94%.
• In rapidly progressive disease, Corticosteroids may be administered. As per the protocol, steroids are not required in all children with moderate covid, particularly during the first few days of illness.

How severe disease is categorized in children?

• Children with less than 90% oxygen saturation level are categorized as having severe degree of Covid. They may have severe pneumonia, ARDS, septic shock, MODS, or pneumonia with cyanosis.
• Clinically, the protocol states such children may present with grunting, lethargy, seizure, severe retraction of chest.

What is recommended treatment for them?

• As per the protocol, they should be assessed for thrombosis; haemophagocytic lymphohistiocytosis (HLH) and organ failure.
• It suggests investigation for complete blood counts, renal and liver function tests, and chest X-ray.
• Intravenous fluid therapy and corticosteroids are recommended- dexamethasone at 0.15 mg/kg per dose (maximum dose of 6 mg two times a day is preferred)
• The protocol emphasizes that for anti-viral agents such as remdesivir, there is a lack of sufficient safety and efficacy data in patients under 19 years.
• For treating children with severe disease, there is no role of the anti-malaria drug hydroxychloroquine, ivermectin, anti-viral favipiravir as well as anti-HIV drugs lopinavir/ritonavir.