ACR has created two new task forces to address pediatric concerns during the SARS-CoV-2 (COVID-19) pandemic. The first is the COVID-19 Pediatric Rheumatology Clinical Guidance Task Force and the other is the Multi-System Inflammatory Syndrome in Children (MIS-C) and COVID-19 Related Hyperinflammation Task Force.
On June 18th, both task forces have released new clinical guidance and recommendations for the care of pediatric patients in the context of COVID-19. All recommendations are based on current knowledge and will be updated as new scientific evidence accumulates.
For the COVID-19 Clinical Guidance for Pediatric Patients with Rheumatic Disease, recommendations include, but are not limited to, the following:
- Routine ophthalmologic surveillance of patients at high risk for chronic uveitis or with a history of uveitis should continue on schedule via in-person visits with slit lamp examination.
In ongoing treatment of pediatric patients who do not have COVID-19 exposure or infection:
- NSAIDs, hydroxychloroquine (HCQ), angiotensin-converting enzyme inhibitor (ACEi)/ angiotensin II receptor blocker (ARBs), colchicine, conventional DMARD (CDMARD), biologic DMARDs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) may be continued or initiated to control underlying disease. Glucocorticoids may be continued or initiated, using the lowest dose possible to control underlying disease.
- For pediatric patients with life and/or organ threatening manifestations, high dose oral or intravenous “pulse” glucocorticoids and cyclophosphamide may be initiated to control underlying disease.
In pediatric patients with ongoing treatment who have close/household exposure to COVID-19:
- Initiation of high dose oral or intravenous glucocorticoids should be delayed for 1-2 weeks, if deemed safe by the treating provider, for pediatric patients with non-life and/or organ threatening manifestations. For those patients with life and/or organ threatening manifestations, the initiation of high dose oral or intravenous glucocorticoids should not be delayed.
In patients with ongoing treatment of pediatric patients with asymptomatic COVID-19 infection:
- NSAIDs, HCQ, colchicine, cDMARDs, bDMARDs, tsDMARDs, cyclophosphamide or rituximab may be continued, if necessary, to control underlying disease.
In patients with probable or confirmed COVID-19 infection:
- cDMARDs, bDMARDs (except IL-1 and IL-6 inhibitors), and tsDMARDs should be temporarily delayed or withheld, and IL-1 and IL-6 inhibitors may be continued, if necessary, to control underlying disease.
For the Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 and Hyperinflammation in COVID-19, the guidance offers direction on diagnostic evaluation of MIS-C, compares and contrasts MIS-C and Kawasaki Disease, and provides general recommendations for cardiac management, immunotherapy treatment, and anti-blood clotting therapies in MIS-C. Recommendations include, but are not limited to, the following:
- MIS-C and Kawasaki Disease unrelated to COVID-19 infections may share overlapping clinical features, including conjunctival injection, oropharyngeal findings (red and/or cracked lips, strawberry tongue), rash, swollen and/or erythematous hands and feet, and cervical lymphadenopathy.
- For cardiac management, EKGs should be performed at a minimum of every 48 hours in MIS-C patients who are hospitalized as well as during follow-up visits.
- For anti-blood clotting therapy, the guidance recommends treatments of daily, low dose aspirin, of no more than 81 mg/day, be used in patients with MIS-C and Kawasaki Disease-like features and/or those with a high platelet count (≥450,000/𝜇L). This treatment should be continued until normalization of platelet count and confirmed normal coronary arteries at ≥4 weeks after diagnosis. Treatment with aspirin should be avoided in patients with a platelet count of ≤80,000/𝜇L.
- Children with severe respiratory symptoms due to COVID-19 with any of the following should be considered for immunotherapy: acute respiratory distress syndrome, shock/cardiac dysfunction, elevated lactate dehydrogenase enzyme, D-dimer, IL-6, IL-2R, and/or ferritin, and depressed lymphocyte count, albumin, and/or platelet count. Glucocorticoids may be considered for use as immunomodulatory therapy in patients with COVID-19 and hyperinflammation (as outlined in the previous statement).
The full list of guidance statements can be found on the ACR website at https://www.rheumatology.org/